Form 21P-0847 Request for Substitution of Claimant upon Death of Claim

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE REQUEST FOR
SUBSTITUTION OF CLAIMANT UPON DEATH OF CLAIMANT
GENERAL INFORMATION
38 U.S.C. section 5121a, Substitution in case of death of claimant. It provides that if a claimant dies while a claim
or appeal for any benefit under a law administered by the Secretary is pending, a living person who would be
eligible to receive accrued benefits due to the claimant under section 5121(a) of this title may, not later than one
year after the date of the death of the claimant, request to be substituted as the claimant for the purposes of
processing the claim to completion.
The new statute allows a person who could be considered an accrued benefits claimant to substitute for a
deceased claimant to continue adjudication of the deceased claimant's claim.
SPECIFIC INSTRUCTIONS
Section 1
In this section, give us the pertinent identifying information to include name, claim and/or social security numbers,
and date of birth of the veteran.
Section 2
Provide us with the substituting claimants' pertinent contact information to include name, address, contact
numbers, and mail address.
Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our Internet
website at http://www.va.gov/directory or in the government pages of your telephone book under "United States
Government, Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want to be the substitute for the deceased claimant, write us a letter to
revoke your request.

VA FORM
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21P-0847

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OMB Approved No. 2900-0740
Respondent Burden: 5 minutes
Expiration Date: XXXXXXX
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

REQUEST FOR SUBSTITUTION OF CLAIMANT UPON
DEATH OF CLAIMANT
INSTRUCTIONS: Use this form if you want to request to substitute the claim of a deceased claimant.
SECTION I - VETERAN'S IDENTIFYING INFORMATION

1. FIRST, MIDDLE INITIAL, LAST NAME OF DECEASED CLAIMANT (Print clearly)

2. VETERAN'S FILE NUMBER (If applicable)

3. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (Month, day, year)

5. VETERAN'S DATE OF DEATH (Month, day, year)

Day

Month

Year

Month

Day

Year

SECTION II - SUBSTITUTE CLAIMANT INFORMATION
I have interest in the claim of the deceased and request to be substituted as the claimant. I am eligible to receive accrued benefits due the deceased
claimant and I am eligible to be a substitute claimant under section 5121(a) of title 38.
6. FIRST, MIDDLE INITIAL, LAST NAME OF SUBSTITUTE CLAIMANT (Print clearly)

7. RELATIONSHIP TO DECEASED

8. CLAIMANT'S SOCIAL SECURITY NUMBER

9. ADDRESS OF CLAIMANT (No. and Street or rural route, City or P.O., State and ZIP Code)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

10. CLAIMANT'S TELEPHONE NUMBER(S)
A. DAYTIME PHONE NUMBER

B. EVENING PHONE NUMBER

C. CELL PHONE NUMBER

11. E-MAIL ADDRESS (Optional) (NOTE: By providing your E-mail address you provide consent for VA to contact you via E-mail
and that those E-mails may contain personal identifiable information. However, VA will never include your SSN in E-mail
correspondence.)

12. FAX NUMBER (If applicable)

13. REMARKS

14A. SIGNATURE (Do NOT print)

14B. DATE SIGNED

PRIVACY ACT INFORMATION: 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 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, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum benefits under the law.
The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. You are
required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may
disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine eligibility for payment of substitution benefits under 38 U.S.C. 5121(a). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 5 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. 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
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21P-0847