Form 21-0538 Mandatory Verification of Dependents

OMB Approved No. 2900-0500
Respondent Burden: 10 Minutes
Expiration Date: 12/31/2020

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

MANDATORY VERIFICATION OF DEPENDENTS

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2.
We use this form to determine continued eligibility to the additional allowance for dependents. For more
information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are
available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs,
Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely
fill in each applicable circle to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
Country

State/Province

ZIP Code/Postal Code

6.TELEPHONE NUMBER (Include Area Code)

7. E-MAIL ADDRESS

I agree to receive electronic correspondence from VA in regards to my claim.

Enter International Phone Number
(If applicable)

SECTION II: STATUS CERTIFICATION
8. HAS THE STATUS OF YOUR DEPENDENT(S) CHANGED?

YES

NO

o If "Yes," complete the section below that refers to the dependent(s) whose status has changed.
o If "No," sign this form (Section V) and disregard the remaining sections of this form.
NOTE: If you have additional dependents not listed on the letter attached to this form, complete and submit VA Form 21-686c, Application Request to Add and/or Remove
Dependents, and if claiming a child aged 18-23 years and in school, complete VA Form 21-674, Request for Approval of School Attendance. VA forms are available at
www.va.gov/vaforms.

SECTION III: CHANGE IN SPOUSE STATUS
9. HOW DID STATUS CHANGE?
DATE ENDED (MM/DD/YYYY):

REASON MARRIAGE ENDED
Annulment

MARRIAGE ENDED
DEATH

Divorce

Declared Void

DATE OF DEATH (MM/DD/YYYY):

SECTION IV: CHANGE IN CHILD(REN)'S STATUS
NOTE: If your child has been adopted out of your family, input the date the adoption was finalized. If you have more than four children whose status has changed, use a
separate VA Form 21-0538.
10A. CHILD'S NAME

10B. HOW STATUS CHANGED
DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because of
medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.
LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):
STEPCHILD IS NO LONGER
A MEMBER OF HOUSEHOLD
VA FORM 21-0538, SEP 2020

SUPERSEDES VA FORM 21-0538, DEC 2017.

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV: CHANGE IN CHILD(REN)'S STATUS (CONTINUED)
11A. CHILD'S NAME

11B. HOW STATUS CHANGED
DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because
of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.
STEPCHILD IS NO LONGER
A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

12A. CHILD'S NAME

12B. HOW STATUS CHANGED
DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because
of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.
STEPCHILD IS NO LONGER
A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

13A. CHILD'S NAME

13B. HOW STATUS CHANGED
DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because
of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.
STEPCHILD IS NO LONGER
A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

SECTION V: CERTIFICATION AND SIGNATURE
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
14A. SIGNATURE OF VETERAN (REQUIRED)

14B. DATE SIGNED (MM/DD/YYYY)

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title
5, Code of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the
collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA
benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education,
Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. You must give
us your and your dependents SSN account information. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under
Title 38 U.S.C. 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute
of law in effect prior to January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies
for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit
program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for an additional allowance for your spouse and/or child(ren). 38 U.S.C. 1115, Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the information and
complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on
the OMB Internet page at www.reginfo.gov/public/do/PRAMain If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.
VA FORM 21-0538, SEP 2020

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