Form 29-541 Certificate Showing Residence and Heirs of Deceased Vete

OMB Control No. 2900-0469
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

1. INSURANCE FILE NUMBER

CERTIFICATE SHOWING RESIDENCE AND HEIRS OF
DECEASED VETERAN OR BENEFICIARY

2. NAME OF INSURED (First, Middle, Last)

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 identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel
Programs of U.S. Government Life Insurance- VA, and published in the Federal Register. Your obligation to respond is required to obtain this benefit.
RESPONDENT BURDEN: We need this information to determine your eligibility for a death benefit. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 30 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 http://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.
3. THE QUESTIONS REFER TO THE VETERAN OR BENEFICIARY:

(Give first, middle, last name)

4A. ARE THERE HEIRS TO THIS ESTATE?
YES

NO

4B. HAS THERE BEEN OR WILL THERE BE A COURT-APPOINTED
EXECUTOR OR ADMINISTRATOR APPOINTED FOR THIS ESTATE?
(If "Yes," see note below. If "No," complete remaining items)
NO
YES

NOTE: If there has been or will be an executor or administrator appointed, furnish letters testamentary or letters of administration. Skip the
remaining items, sign on reverse, and return this form with your letters.
5. STATE OF RESIDENCE AT TIME OF DEATH (EXCLUDING MILITARY SERVICE)

IMPORTANT: Items 6 through 9 - Write the word "NONE" in each item where there is no next of kin. If any information is unknown to the
witnesses, the words "DO NOT KNOW" should be written in the space provided. If additional space is required, attach a separate sheet. If separate
sheets are necessary, each sheet must be signed.
6. SPOUSE OF DECEASED VETERAN/BENEFICIARY
A. NAME OF SPOUSE

A. NAME(S) OF CHILD(REN)
(Include illegitimate, adopted,
deceased and unborn child(ren))

A. NAME OF PARENT

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH

(If deceased)

7. ALL CHILD(REN) OF DECEASED VETERAN/BENEFICIARY
D. DATE OF
C. ADDRESS / PHONE NUMBER
B. AGE
DEATH
/ EMAIL
(If deceased)

8. PARENTS OF DECEASED VETERAN/BENEFICIARY
C. ADDRESS / PHONE NUMBER / EMAIL
B. AGE

E. YEAR OF MARRIAGE

E. PARENTS OF
CHILD(REN) NAMED IN
BLOCK 7A

D. DATE OF DEATH (If deceased)

PARENT

PARENT

IMPORTANT: If spouse, child(ren), or parent(s) survive the VETERAN/BENEFICIARY, skip to Item 10 on the reverse.
VA FORM
XXXX

29-541

SUPERSEDES VA FORM 29-541, MAY 2018,
WHICH WILL NOT BE USED.

Page 1

9. BROTHER(S) AND SISTER(S) OF DECEASED VETERAN/BENEFICIARY
(STATE WHETHER FULL, HALF-BLOOD, OR ADOPTED)
A. NAME(S) OF BROTHER(S) AND
SISTER(S)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH (If deceased)

NAME(S) OF CHILD(REN)
OF DECEASED BROTHER(S)
AND SISTER(S)

The fastest and most secure way for insureds and beneficiaries to send the
application to VA Insurance is to use the document upload service at:
https://insurance.va.gov/home/IDU.

Or mail to:

VA Insurance Center
P.O. Box 7208
Philadelphia, PA 19101

WE CERTIFY THAT to the best of our knowledge and belief, the above named are the only relatives of the veteran/beneficiary,
living or dead, and that the foregoing statements are true.
10. FIRST WITNESS INFORMATION

11. SECOND WITNESS INFORMATION

A. FIRST, MIDDLE, LAST NAME

A. FIRST, MIDDLE, LAST NAME

B. DAYTIME TELEPHONE NUMBER (Include Area Code)

B. DAYTIME TELEPHONE NUMBER (Include Area Code)

C. RELATIONSHIP TO DECEASED

C. RELATIONSHIP TO DECEASED

D. SIGNATURE

D. SIGNATURE

PENALTY: The statements contained herein are made with the full knowledge of the penalties imposed by law for making false statements of a material fact.

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
become 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/.
VA FORM 29-541, XXXX