21-0788 Information Regarding Apportionment of Beneficiary's Awa

OMB Approved No. 2900-0666
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

INFORMATION REGARDING APPORTIONMENT OF
BENEFICIARY'S AWARD
INSTRUCTIONS: All or part of a veteran's disability award may be apportioned (paid) to the
veteran's spouse, child, or dependent parent. A surviving spouse's award may also be
apportioned for the veteran's child(ren). For additional space, use Item 16, Remarks or attach
a separate sheet, indicating the item number to which the answers apply. Make sure to write
the veteran's name and VA claim number on any attachments to the form. Please read the
Privacy Act and Respondent Burden information on page 2 before completing the form.

NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to expedite processing the form.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Month
Day
Year

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II: CLAIMANT OR CUSTODIAN/GUARDIAN (if for minor child) INFORMATION
6. NAME OF CLAIMANT OR CUSTODIAN /GUARDIAN COMPLETING THIS FORM (First, Middle Initial, Last)

7. CLAIMANT'S SOCIAL SECURITY NUMBER

8. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

9. TELEPHONE NUMBER (Include Area Code)

10. EMAIL ADDRESS (Optional)

SECTION III: APPORTIONMENT INFORMATION (Only complete the portion of this section that applies to you)
11. PERSON(S) YOU ARE REQUESTING AN APPORTIONMENT FOR:
A. NAME OF APPORTIONEE (First, Middle, Last)

VA FORM
XXX XXXX

21-0788

B. PROVIDE CHILD/SPOUSE SOCIAL SECURITY NUMBER

SUPERSEDES VA FORM 21-0788, NOV 2014,
WHICH WILL NOT BE USED.

C. WHAT IS HIS/HER RELATIONSHIP TO VETERAN?

Page 1

VETERAN'S SOCIAL SECURITY NUMBER

SECTION III: APPORTIONMENT INFORMATION (Only complete the portion of this section that applies to you) (Continued)
12A. HAS THE VETERAN BEEN CLAIMING A STEP CHILD(REN)?
YES

(If "Yes," complete Item 12B)

NO

12B. IS/ARE THE STEP CHILD(REN) STILL LIVING IN THE VETERAN'S HOUSEHOLD?
YES

NO

(If "No," provide the date the step child(ren) left
the veteran's household)(MM/DD/YYYY)

13. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT, IS HE/SHE LIVING WITH ANOTHER PERSON AND HOLDING HIMSELF/HERSELF OUT OPENLY
TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON?
YES

(If "Yes," provide explanation):

NO
14. HAS/HAVE THE VETERAN'S CHILD(REN) BEEN LEGALLY ADOPTED BY ANOTHER PERSON?
YES

NO

15A. SELECT THE SITUATION THAT APPLIES TO YOU (Check applicable box and complete either Item 15B or 15C)
(If not applicable skip to Section IV)

Veteran is incarcerated for conviction of a felony for more than 60 days (38 U.S.C. § 5313)
Surviving spouse is incarcerated for conviction of a felony for more than 60 days (38 U.S.C. § 5313)
Veteran is incompetent, without fiduciary, and is receiving institutional care by the United States or a political subdivision and the veteran's
benefits are not being paid to the veteran's spouse (38 U.S.C. § 5307 and 5502)
15B. PROVIDE THE NAME AND ADDRESS OF THE PRISION WHERE THE VETERAN
OR SURVIVING SPOUSE IS INCARCERATED

15C. PROVIDE THE NAME AND ADDRESS OF THE INSTITUTION WHERE
THE VETERAN IS A PATIENT RECEIVING CARE

SECTION IV - REMARKS
16. REMARKS (If any)

SECTION V - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
17A. SIGNATURE OF VETERAN/CLAIMANT OR CUSTODIAN/GUARDIAN (REQUIRED)

17B. DATE SIGNED (MM/DD/YYYY)

PRIVACY ACT INFORMATION - 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 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, 58VA 21/22/28, 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.
RESPONDENT BURDEN - We need this information to determine whether an apportionment of VA disability or death benefits may be made (38 U.S.C. 5307). Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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.

PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of anystatement or evidence
of a material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-0788, XXX XXXX

Page 2