21P-524 Statement of Person Claiming to Have Stood in Relation o

OMB Control No. 2900-0059
Respondent Burden: 2 Hours
Expiration Date: XXXXXX

(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

STATEMENT OF PERSON CLAIMING TO HAVE
STOOD IN RELATION OF PARENT
INSTRUCTIONS: Answer all questions as fully as possible. If you do not know the answer, enter "Unknown." If the answer is
none, enter "None" or "N/A." If additional space is needed, attach a SIGNED sheet of paper indicating the item number to
which the answer apply. Parts II and III should each be completed by disinterested persons who have personal knowledge of the
relationship which existed between the claimant and the veteran.
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse
resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103
(c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
1. FIRST, MIDDLE, LAST NAME OF DECEASED VETERAN (Type or Print)
2. VA FILE NUMBER
XC/XSS PART I - STATEMENT OF CLAIMANT

3A. CLAIMANT'S NAME (First, middle initial, last)

3B. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

ZIP Code/Postal Code

Country

3C. DAYTIME TELEPHONE NUMBER (Include Area Code)

3D. EVENING TELEPHONE NUMBER (Include Area Code)

4. YOUR RELATIONSHIP TO VETERAN BY BLOOD OR MARRIAGE

(Stepfather,Sister, etc., if none state "None")

6A. ARE YOU MARRIED TO A PARENT OF THE VETERAN?
YES

NO

5A. CLAIMANT'S SOCIAL SECURITY NUMBER

6B. DATE OF MARRIAGE

5B. CLAIMANT'S DATE OF BIRTH

6C. PLACE OF MARRIAGE

(If "Yes", complete 6B and 6C)
INFORMATION ABOUT THE VETERAN

7A. VETERAN'S DATE OF BIRTH

7B. VETERAN'S SOCIAL SECURITY NUMBER

8. PLACE OF BIRTH

9. DATE OF DEATH

10. PLACE OF DEATH

11A. NAME OF VETERAN'S OWN FATHER (If deceased, complete 11B)

12A. NAME OF VETERAN'S OWN MOTHER (If deceased, complete 12B)

11B. DATE OF DEATH OF VETERAN'S OWN FATHER

12B. DATE OF DEATH OF VETERAN'S OWN MOTHER

11C. ADDRESS OF VETERAN'S OWN FATHER, IF LIVING

12C. ADDRESS OF VETERAN'S OWN MOTHER, IF LIVING

13A. WAS VETERAN EVER MARRIED?

13B. FULL NAME OF SPOUSE

YES

NO

(If "Yes", complete 13B and 13D)

13C. DATE OF MARRIAGE

14A. DATE VETERAN WAS PLACED IN YOUR
CUSTODY OR CARE

13D. ADDRESS OF SPOUSE, IF LIVING

14B. NAME AND ADDRESS OF ORGANIZATION, INSTITUTION, OR PERSON THAT PLACED THE VETERAN IN YOUR
CUSTODY OR CARE

IMPORTANT - If you entered into a written agreement at the time veteran was placed in your custody or care, attach a copy of the agreement.
15. CIRCUMSTANCES OF YOUR OBTAINING CUSTODY OR CARE OF THE VETERAN (Explain fully)

VA FORM
XXXX

21P-524

SUPERSEDES VA FORM 21-524, AUG 2017,
WHICH WILL NOT BE USED.

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VETERAN'S SSN
INFORMATION ABOUT THE VETERAN (Continued)
16. NAME OF HEAD OF HOUSEHOLD IN WHICH YOU LIVED AT TIME YOU ASSUMED ALLEGED RELATIONSHIP OF PARENT TO VETERAN

17A. NAME AND ADDRESS OF PERSON WHO PROVIDED
VETERAN WITH A PLACE TO LIVE AFTER YOU ASSUMED
ALLEGED RELATIONSHIP OF PARENT TO VETERAN

17B. PERIOD(S) OF TIME THIS PERSON
FURNISHED VETERAN WITH A PLACE
TO LIVE
FROM

17C. ADDRESSES AT WHICH VETERAN LIVED DURING
PERIOD SHOWN IN ITEM 17B

TO

18A. DID YOU PROVIDE FOR SCHOOLING OR TRAINING OF VETERAN?
YES

NO

(If "Yes", complete Items 18B, 18C and 18D)
18B. DATE

FROM

TO

18D. TYPE OF COURSE OR
TRAINING TAKEN

18C. NAME AND ADDRESS OF SCHOOL

19. APPROXIMATE AMOUNTS SPENT BY YOU FOR VETERAN'S SUPPORT, CLOTHING, SCHOOLING, AND OTHER NECESSARY EXPENSES (Explain fully)

INFORMATION ABOUT SURVIVING BROTHERS AND SISTERS OF VETERAN
20A. NAME

20B. AGE

20C. ADDRESS

ORGANIZATIONS, INSTITUTIONS, AND PERSONS THAT CONTRIBUTED TO VETERAN'S SUPPORT (If none, state "NONE")
21A. NAME AND ADDRESS

21B. AMOUNT OF CONTRIBUTION

21C. PURPOSE

21D. DATE OF CONTRIBUTION

ORGANIZATIONS, INSTITUTIONS, AND PERSONS THAT CONTRIBUTED TO VETERAN'S SUPPORT (If none, state "NONE")
22A. NAME

VA FORM 21P-524, XXXX

22B. ADDRESS

(If person is deceased, give date of death.)

22C. DATES OF CUSTODY OR CARE

(If exact dates are unknown give
approximate dates)

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VETERAN'S SSN
INFORMATION ABOUT THE RELATIONSHIP
23A. DID VETERAN CONTRIBUTE TO YOUR SUPPORT AT ANY TIME?
YES

NO

(If "Yes", complete Item 23B)

23B. AMOUNT CONTRIBUTED AND CIRCUMSTANCES UNDER WHICH CONTRIBUTED (Explain fully)

INFORMATION ABOUT VETERAN'S EMPLOYMENT
24A. WAS VETERAN EMPLOYED DURING PERIOD HE/SHE WAS IN YOUR CUSTODY OR CARE?
YES

NO

(If "Yes", complete Items 24B, 24C and 24D)

24B. DATE OF EMPLOYMENT

24C. NAME AND ADDRESS OF EMPLOYER

24D. AMOUNT EARNED

25. DID THE VETERAN IN A NOTE, LETTER, DOCUMENT, INSURANCE POLICY OR ANY RECORD, REFER TO YOU AS A PARENT?
YES

NO

(If "Yes", explain fully)

IMPORTANT - Attach letters, notes, records or other evidence which tend to show the relationship which existed between you and the veteran. This
evidence will be returned to you, if requested.
26. OTHER FACTS WHICH SHOW THE RELATIONSHIP THAT EXISTED BETWEEN YOU AND THE VETERAN

CERTIFICATE AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
27. DATE

28. SIGNATURE OF CLAIMANT

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

NOTE: Signatures made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signature
and addresses of the witnesses must be shown below.
29. SIGNATURE OF WITNESS

30. ADDRESS OF WITNESS

31. SIGNATURE OF WITNESS

32. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or evidence of a
material fact, knowing it to be false.
VA FORM 21P-524, XXXX

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VETERAN'S SSN
PART II - STATEMENT OF DISINTERESTED PERSON NO. 1

NOTE: Read Instructions on page 1 before completing.
1. NAME AND ADDRESS OF DISINTERESTED PERSON

2. AGE

3. OCCUPATION

4. YOUR RELATIONSHIP TO DECEASED VETERAN
5. LENGTH OF TIME YOU KNEW VETERAN
6. YOUR RELATIONSHIP TO CLAIMANT

7. LENGTH OF TIME YOU HAVE KNOWN CLAIMANT

8. WERE YOU IN A POSITION PERSONALLY TO OBSERVE THE CONDUCT AND ATTITUDE OF THE CLAIMANT AND THE VETERAN TOWARD EACH OTHER?
YES

NO

(If "Yes", explain fully your position to make these observations and give number of months or years you observed this relationship)

9. FACTS BASED ON YOUR PERSONAL KNOWLEDGE WHICH SHOW WHETHER OR NOT CLAIMANT ACTED AS "PARENT" TO THE VETERAN (Explain in detail,

giving facts relating to veteran's support, guidance, training. etc.)

INFORMATION ABOUT PERIODS OF TIME VETERAN LIVED IN SAME HOUSEHOLD WITH CLAIMANT
10A. DO YOU KNOW OF YOUR OWN KNOWLEDGE WHETHER THE VETERAN LIVED IN THE SAME HOUSEHOLD WITH THE CLAIMANT?
YES

NO

(If "Yes", complete Items 10B and 10C)
10B. DATES

FROM

TO

10C. ADDRESS

11. DO YOU KNOW OF YOUR PERSONAL KNOWLEDGE WHO SUPPORTED THE VETERAN?
YES

NO

(If "Yes", explain in detail)

12. DID ANY OTHER PERSONS STAND IN THE RELATIONSHIP OF PARENT TO THE VETERAN?
YES

NO

(If "Yes", explain fully)

13. WHAT IS THE MEANS OF YOUR KNOWLEDGE OF THE INFORMATION FURNISHED IN ITEMS 9 THROUGH 12?

14. PLACES WHERE YOU LIVED, AND DATES OF EACH RESIDENCE, DURING PERIOD CLAIMANT ALLEGED CUSTODY OR CARE OF VETERAN

VA FORM 21P-524, XXXX

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VETERAN'S SSN
PART II - STATEMENT OF DISINTERESTED PERSON NO. 1 (Continued)
CERTIFICATE AND SIGNATURE OF DISINTERESTED PERSON

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15. DATE

16. SIGNATURE OF DISINTERESTED PERSON

WITNESSES TO SIGNATURE OF DISINTERESTED PERSON IF MADE BY "X" MARK

NOTE: Signatures made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signature
and addresses of the witnesses must be shown below.
17. SIGNATURE OF WITNESS

18. ADDRESS OF WITNESS

19. SIGNATURE OF WITNESS

20. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or evidence of a
material fact, knowing it to be false.
PART III - STATEMENT OF DISINTERESTED PERSON NO. 2

NOTE: Read Instructions on page 1 before completing.

1. NAME AND ADDRESS OF DISINTERESTED PERSON (Type or Print)

2. AGE

3. OCCUPATION

4. YOUR RELATIONSHIP TO DECEASED VETERAN
5. LENGTH OF TIME YOU KNEW VETERAN
6. YOUR RELATIONSHIP TO CLAIMANT

7. LENGTH OF TIME YOU HAVE KNOWN CLAIMANT

8. WERE YOU IN A POSITION PERSONALLY TO OBSERVE THE CONDUCT AND ATTITUDE OF THE CLAIMANT AND THE VETERAN TOWARD EACH OTHER?
YES

(If "Yes", explain fully your position to make these observations and give number of months or years you observed this relationship)

NO

9. FACTS BASED ON YOUR PERSONAL KNOWLEDGE WHICH SHOW WHETHER OR NOT CLAIMANT ACTED AS "PARENT" TO THE VETERAN (Explain in detail,

giving facts relating to veteran's support, guidance, training, etc.)

INFORMATION ABOUT PERIODS OF TIME VETERAN LIVED IN THE SAME HOUSEHOLD WITH CLAIMANT
10A. DO YOU KNOW OF YOUR OWN KNOWLEDGE WHETHER THE VETERAN LIVED IN THE SAME HOUSEHOLD WITH THE CLAIMANT?
YES

NO

(If "Yes", complete Items 10B and 10C)
10B. DATES

FROM

TO

10C. ADDRESS

11. DO YOU KNOW OF YOUR PERSONAL KNOWLEDGE WHO SUPPORTED THE VETERAN?
YES

NO

(If "Yes", explain in detail)

VA FORM 21P-524, XXXX

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VETERAN'S SSN
PART III - STATEMENT OF DISINTERESTED PERSON NO. 2 (Continued)
12. DID ANY OTHER PERSONS STAND IN THE RELATIONSHIP OF PARENT TO THE VETERAN?
YES

NO

(If "Yes", explain fully)

13. WHAT IS THE MEANS OF YOUR KNOWLEDGE OF THE INFORMATION FURNISHED IN ITEMS 9 THROUGH 12?

14. PLACES WHERE YOU LIVED, AND DATES OF EACH RESIDENCE, DURING PERIOD CLAIMANT ALLEGED CUSTODY OR CARE OF VETERAN

CERTIFICATE AND SIGNATURE OF DISINTERESTED PERSON

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15. DATE

16. SIGNATURE OF DISINTERESTED PERSON

WITNESSES TO SIGNATURE OF DISINTERESTED PERSON IF MADE BY "X" MARK

NOTE: Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures
and addresses of the witnesses must be shown below.
17. SIGNATURE OF WITNESS

18. ADDRESS OF WITNESS

19. SIGNATURE OF WITNESS

20. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or evidence of a
material fact, knowing it to be false.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what have been authorized under the Privacy Act of 1974 or Title 38, Code of Federal
Regulations 1.576 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, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register.
Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101
(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a 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 eligibility for service-connected death benefits (38 U.S.C. 1315 and 5101). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 2 hours 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. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21P-524, XXXX

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