VA Form 21P-534 Application for Dependency and Indemnity Compensation, S

GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION (DIC), SURVIVORS PENSION AND ACCRUED
BENEFITS BY A SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21P-534

Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?

If you have any questions about this form, how to fill it out, or about VA benefits, contact your nearest VA regional office.
You can locate the address of the nearest regional office in your telephone book blue pages under "United States Government, Veterans" or call
1-800-827-1000 (Hearing Impaired TDD line is 711). You may also contact VA by Internet at https://iris.custhelp.va.gov.

B. What is the purpose of VA Form 21P-534?
Use VA Form 21P-534 to apply for:
VA benefits you may be entitled to receive as a surviving spouse or child
of a deceased veteran, and
any money VA owes the veteran but did not pay prior to his or her death (accrued benefits).
NOTE: If you apply for any one of these benefits, the law requires that we also consider you for the others.

C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security (SS) benefits by using the SSA-24 form attached to this VA Form (see pages 12 and 13). You don't have to apply
if you don't want to or have already done so. If you do want to apply, fill it out and leave it attached. We will send it to the Social Security
Administration for you. They will then contact you.

D. What are dependency and indemnity compensation (DIC) and Survivors Pension benefits, and how does VA decide what I
will or will not receive?
1. Dependency and indemnity compensation may be payable when:
a veteran's death occurred while on active service, or
a veteran dies of a service-connected disability or disabilities that was/were either the principal or contributory cause of death, or
a veteran died from a non-service connected injury or disease AND was receiving, or entitled to receive VA compensation for a serviceconnected disability rated totally disabling;
For at least 10 years immediately before death; or
For at least 5 years after the veteran's release from active duty preceding death; or
For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999.
2. Survivors Pension may be payable when:
the death of a veteran with wartime service is not due to service, and
income and assets are within applicable limits.

VA pays pension based on the amount of family income and assets and the number of dependent children. This is based on law. VA must include as
income all sources that Federal law specifies. If there is no surviving spouse, pension may be payable on behalf of a child or children.
You must provide information about the Social Security benefits you and your dependents receive. Report the gross amount you and your dependents
receive monthly before deductions are taken out. If you have a copy of your most recent Social Security award letter, please include a copy of the letter
with your application.
You must tell us if you or your dependents receive or received income from sources other than Social Security. Please also report if you or your
dependents own your primary residence and the value of your assets and your dependents' assets. Your assets do include your spouse's assets.
Although your assets do not include your child's assets, you must tell us if your child has significant assets.
Assets means the fair market value of all property that an individual owns, including all real and personal property (excluding the value of the primary
residence including the residential lot area, not to exceed 2 acres) less the amount of mortgages or other encumbrances specific to the mortgaged or
encumbered property). Personal property means the value of personal effects that are in excess of being suitable and consistent with a reasonable mode
of life.
Unless a claim for dependency and indemnity compensation or Survivors Pension is filed within 1 year from the date of the veteran's death, that benefit
is not payable from a date earlier than the date the claim is received in the VA.
If it is determined that you are entitled to DIC and death pension, we will pay you whichever benefit entitles you to the most money. Benefit rates and
income limits are frequently changed, so it is not possible to keep this information current in these instructions. You can find out what the current
income limitations and rates of benefits are by contacting your nearest VA regional office.

VA FORM
XXX XXXX

21P-534

SUPERSEDES VA FORM 21-534, JAN 2021,
WHICH WILL NOT BE USED.

General Instructions

PAGE 1

E. How do I apply for special monthly pension or special monthly DIC?
VA may pay increased survivor benefits to a surviving spouse who is blind, a patient in a nursing home due to mental or physical incapacity, requires
the aid of another person to perform personal functions required in everyday living, such as bathing, feeding, dressing yourself, attending to the wants
of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your daily environment (38 Code of Federal Regulations 3.352(a)); or
who is permanently confined to his or her immediate premises because of a permanent disability. If you wish to apply for this benefit, check "Yes" for
Item 31.

F. How do I complete my application?
Print all answers clearly. If an answer is "none" or "0," write that. Your answer to every question is important to help us complete your claim. If you
do not know the answer, write "unknown." For additional space, use Item 49, "Remarks, " or attach a separate sheet, indicating the item number to
which the answers apply. Make sure you sign and date this application (Items 46A and 46B).

Note: If the claim is being made on behalf of a minor or incompetent person, the application form should be completed and filed by
the legal guardian. If no legal guardian has been appointed, it may be completed and filed by some person acting on behalf of the
minor or incompetent person.
G. What do I do when I have completed my application?
When you have completed this application mail it or take it to a VA regional office. Be sure to attach any materials that support and explain your claim.
Also, make a photocopy of your application and everything that you submit to VA before mailing it. You can find the mailing address of your local VA
regional office at www.va.gov/directory.

H. How can I assign someone to act as my representative?
A representative can be a VA accredited Veterans Service Organization or other service organization that the Secretary of Veterans Affairs recognizes
or, a VA accredited attorney or claims agent. Agents and attorneys can charge you for services that you get from them only after the Board of
Veteran's Appeals (BVA) gives you their final decision about your application. That means you can use an attorney during any stage of your
application for benefits. However, the agent or attorney cannot charge you for services unless you are trying to resolve a dispute with VA after BVA
has made a decision about your claim.
If you want to use a representative to help you with your application, contact the nearest VA office. Depending on the type of representative you want to
designate, we will send you one of the following forms:
• VA Form 21-22, Appointment of a Veterans Service Organization as Claimant's Representative, or
• VA Form 21-22A, Appointment of Individual as Claimant's Representative.
You may also download these forms at www.va.gov/vaforms. If you have already designated a representative, no further action is required on your part.

I. What if I believe that VA has made an error in processing or deciding my benefits?
You can ask for a personal hearing at any time during the processing of your claim. That means you can ask for the hearing while VA is processing your
claim or after VA has made a decision. You should contact the nearest VA office and tell them that you want a personal hearing on your case.
Someone in the local VA office will arrange a time and place for your hearing. At this hearing, you can bring witnesses. VA will record whatever you
and your witnesses say during the hearing and include it in the official record. VA will furnish the hearing room and officials, and prepare a transcript of
the hearing. VA cannot pay your expenses or the expenses of anyone you want to bring with you to the hearing.
FEES FOR CLAIMS
Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be
charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans
Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a
fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent
has complied with the applicable power-of-attorney and the fee agreement requirements.
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 when you filed your claim (or later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on VA
recognized marriages is available at http:www.va.gov/opa/marriage/.
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, 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your response 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 USC 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. 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 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 death benefits and accrued benefits under 38 U.S.C. 1310 through 1314, 1532 through 1543, and 5121. Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour and 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.
VA FORM 21P-534, XXX XXXX

General Instructions

PAGE 2

OMB Approved No. 2900-0004
Respondent Burden: 1 hour 15 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, SURVIVORS
PENSION AND ACCRUED BENEFITS BY A SURVIVING SPOUSE OR CHILD
(Including Death Compensation if Applicable)

IMPORTANT - Read the attached "General Instructions" before you fill out this form.

PART I - CLAIM INFORMATION (Tell us what you are applying for and what you and the deceased veteran have applied for)
1. DID THE VETERAN EVER FILE A CLAIM WITH VA ?
NO (If "Yes," answer Item 2)
YES

2. WHAT IS THE VA FILE NUMBER? (If known)

3. HAS THE SURVIVING SPOUSE OR CHILD EVER FILED A CLAIM WITH VA?
YES
NO (If "Yes," answer Items 4 through 6)

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

4. WHAT IS THE VA FILE NUMBER? (If known)

5. WHAT IS THE NAME OF THE PERSON ON WHOSE SERVICE THE CLAIM WAS FILED? (First, Middle, Last Name of Veteran)
7. ARE YOU CLAIMING SERVICE CONNECTION FOR CAUSE OF DEATH?

6. WHAT IS YOUR RELATIONSHIP TO THAT PERSON?

YES

NO

PART II - IDENTIFYING INFORMATION (Provide information about you and the deceased veteran)
8. WHAT IS THE VETERAN'S NAME? (First, Middle, Last Name of Veteran) (Suffix - if applicable)

10A. DID THE VETERAN SERVE UNDER ANOTHER NAME?
YES

9. VETERAN'S SOCIAL SECURITY NO.

10B. LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER

NO (If "Yes," answer Item 10B)

11. WHAT IS THE VETERAN'S DATE OF BIRTH (Month, Day, Year)

12. WHAT IS THE VETERAN'S DATE OF DEATH (Month, Day, Year)
(NOTE: Attach a copy of the death certificate unless the veteran
died in active service of the Army, Navy, Air Force, Marine Corps,
or Coast Guard, or in a U.S. government institution)

13. WAS THE VETERAN A FORMER PRISONER OF WAR?

14. WHAT IS YOUR NAME? (First, Middle, Last Name of Veteran's Spouse or Child)

YES

NO

15. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
SURVIVING SPOUSE

16. WHAT IS YOUR ADDRESS (Number and street or rural route, city or P.O., State,

ZIP Code and Country)

CHILD
17. WHAT ARE YOUR TELEPHONE NUMBERS? (Include Area Code)
DAYTIME

18. WHAT IS YOUR E-MAIL ADDRESS?

CELL PHONE

EVENING

20. WHAT IS THE YOUR DATE OF BIRTH (Month, Day, Year)

19. WHAT IS YOUR SOCIAL SECURITY NUMBER?

PART III - VETERAN'S ACTIVE DUTY SERVICE
IMPORTANT: Enter complete information for all periods of service. If more space is needed use Item 49 "Remarks". If the veteran never filed a claim with
VA, attach the original DD214 or a certified copy for each period of service listed. We will return original documents to you.
21A. ENTERED ACTIVE
SERVICE - First Period

(Month, Day, Year)

21B. PLACE ENTERED ACTIVE
SERVICE - First Period

21E. PLACE LEFT ACTIVE
SERVICE - First Period

21H. ENTERED ACTIVE
SERVICE - Second Period

(Month, Day, Year)

21P-534

21D. DATE LEFT ACTIVE
SERVICE - First Period

(Month, Day, Year)

21F. BRANCH OF SERVICE

21I. PLACE ENTERED ACTIVE
SERVICE - First Period

21L. PLACE LEFT ACTIVE
SERVICE - Second Period

VA FORM
XXX XXXX

21C. SERVICE NUMBER

21J. SERVICE NUMBER

21G. GRADE, RANK,
OR RATING

21K. DATE LEFT ACTIVE
SERVICE - Second Period

(Month, Day, Year)

21M. BRANCH OF SERVICE

SUPERSEDES VA FORM 21-534, JAN 2021,
WHICH WILL NOT BE USED.

21N. GRADE, RANK,
OR RATING

PAGE 3

PART IV - MARITAL INFORMATION
(Attach a copy of your marriage certificate showing your marriage to the veteran)
NOTE: You must furnish complete information about all marriages of the surviving spouse and the veteran. If you need additional space, please
attach a separate VA Form 21-686c, Declaration of Status of Dependents, providing the requested information.
If you are claiming benefits as the surviving spouse of the veteran you should complete Items 22A through 28. If you are not the surviving spouse, skip to
Section V.
TELL US ABOUT THE VETERAN'S MARRIAGES
22A. HOW MANY TIMES WAS THE VETERAN MARRIED? (Include marriage to you)

22B. DATE (month, day, year) and PLACE
OF MARRIAGE (city, state or country)

22D. TYPE OF MARRIAGE 22E. HOW MARRIAGE
(ceremonial, common-law,
TERMINATED
proxy, tribal, or other)
(death, divorce)

22C. TO WHOM MARRIED
(first, middle, last name)

22F. DATE (month, day, year) and
PLACE MARRIAGE TERMINATED
(city/state or country)

22G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22D, PLEASE EXPLAIN:

TELL US ABOUT YOUR MARRIAGES
23A. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Include your marriage to the
veteran)
Provide information in Items 23c through 23G for all of your marriages)
23C. DATE (month, day, year) and PLACE
OF MARRIAGE (city/state or country)

23D. TO WHOM MARRIED
(first, middle, last name)

23B. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
YES

23E. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)

NO
23F. HOW MARRIAGE
23G. DATE (month, day, year)
TERMINATED
and PLACE MARRIAGE
(death, divorce, marriage has not
TERMINATED
been terminated)
(city/state or country)

23H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 23E, PLEASE EXPLAIN:
24. WAS A CHILD BORN TO YOU AND THE VETERAN DURING YOUR MARRIAGE
25. ARE YOU EXPECTING THE BIRTH OF THE VETERAN'S CHILD?
OR PRIOR TO YOUR MARRIAGE?
(Answer Item 24 only if you were married to the veteran
YES
NO
YES
NO
less than one year)
26. DID YOU LIVE CONTINUOUSLY WITH THE VETERAN FROM THE DATE
27. WHAT WAS THE CAUSE OF SEPARATION? GIVE THE REASON, DATE(S) AND
DURATION OF THE SEPARATION (IF THE SEPARATION WAS BY COURT ORDER,
OF MARRIAGE TO THE DATE OF HIS/HER DEATH?
ATTACH A COPY OF THE ORDER)
YES

NO

(If "No," complete Item 27)

28. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?
YES

NO

(If "Yes," provide explanation):___________________________________________________________________________________________

PART V - DEPENDENT CHILDREN (Complete ONLY if claiming benefits for a child(ren) of the veteran)
(Skip to Section VI if you are NOT claiming benefits for a child(ren) of the veteran)
TELL US ABOUT THE UNMARRIED CHILDREN OF THE VETERAN
NOTE: You should provide a copy of the public record of birth or a copy of the court record of adoption for each child listed in Item 29A unless the veteran
was receiving additional VA benefits for the child.
If you need additional space, please attach a separate VA Form 21-686c, Declaration of Status of Dependents, providing the requested information
about each child.
IMPORTANT: Skip to Part VI if you are not claiming benefits for any children that meet the following criteria.

∙∙
∙

VA recognizes the veteran's biological children, adopted children, and stepchildren as dependents. These children must be unmarried and:
under age 18, or
at least 18 but under 23 and pursuing an approved course of education, or
of any age if they became permanently unable to support themselves before reaching at 18.

"Seriously disabled" (Item 29H) means that the child became permanently unable to support himself/herself before reaching age 18. Furnish a statement from an
attending physician or other medical evidence which shows the nature and extent of the physical or mental impairment.
Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over age 18 is entitled to receive DIC benefits in his or her own right. A
veteran's child who is seriously disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.
VA FORM 21P-534, XXX XXXX

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PART V - DEPENDENT CHILDREN (Complete ONLY if claiming benefits for a child(ren) of the veteran)
(Skip to Section VI if you are NOT claiming benefits for a child(ren) of the veteran) (Continued)
29A. NAME OF CHILD
(First, middle initial, last name)

29B. DATE (month, day,
year) and PLACE OF
BIRTH
(city/state or country)

29C. SOCIAL
SECURITY
NUMBER

(Check all that apply)
29D.
29F.
29E.
BIOLOGICAL ADOPTED STEPCHILD

29G.
18-23 YEARS
OLD (in school)

29I.
29H.
29J. CHILD
CHILD PREVIOUSLY
SERIOUSLY
DISABLED MARRIED MARRIED

Tell us about the child(ren) listed in Item 29A that do not live with you in Items 30A through 30D.
30A. NAME OF CHILD
(First, middle initial, last name)

30B. CHILD'S COMPLETE ADDRESS
30D. MONTHLY AMOUNT YOU
30C. NAME OF PERSON THE CHILD
(Number and street or rural route, city or P.O., city,
CONTRIBUTE TO THE CHILD'S
LIVES WITH (If applicable)
State, ZIP Code and country)
SUPPORT

$
$
$
PART VI - HOUSEBOUND, IN A NURSING HOME OR REQUIRE AID AND ATTENDANCE
NOTE: If you are claiming aid and attendance allowance and/or housebound benefits because you need the regular assistance of another person, are
having severe visual problems, or are housebound and not in a nursing home, submit a statement from your doctor showing the extent of your disabilities.
If you are in a nursing home, attach a statement signed by an official of the nursing home showing the date you were admitted, the level of care you receive,
the amount you pay out-of-pocket for your care, and whether Medicaid covers all or part of your nursing home costs.
31. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
PROBLEMS, OR ARE CONFINED TO YOUR IMMEDIATE PREMISES?
YES

(If "Yes," please complete and attach with this application VA Form 21-2680, Exam for Housebound Status or Permanent Need for
Regular Aid and Attendance. Please make sure every box is complete and signed by a Physician, Physician Assistance (PA),
Certified Nurse Practitioner (CNP), or Clinical Nurse Specialist (CNS))

NO

32B. PROVIDE THE NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY

32A. ARE YOU NOW IN A NURSING HOME?
YES

NO (If "Yes," answer Items 32B and 32C and submit a statement
from an official of the nursing home that tells us that you are a
patient in the nursing home because of a physical or mental
disability. The statement should include the monthly charge you
are paying out-of-pocket for your care)

32C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
YES

NO

(If "No," answer Item 32D)

32D. HAVE YOU APPLIED FOR MEDICAID?
YES

NO

PART VII - INCOME AND ASSETS
33A. HAVE YOU CLAIMED OR ARE YOU RECEIVING BENEFITS FROM THE SOCIAL SECURITY ADMINISTRATION ON YOUR OWN BEHALF OR ON BEHALF OF
A CHILD OR CHILDREN IN YOUR CUSTODY?
YES

NO (If "Yes," answer Item 40B)

33B. IS SOCIAL SECURITY BASED ON YOUR OWN EMPLOYMENT?
YES

NO

34. HAS A SURVIVING SPOUSE OR CHILD FILED A CLAIM FOR COMPENSATION FROM THE OFFICE OF WORKER'S COMPENSATION PROGRAMS BASED
ON THE DEATH OF THE VETERAN?
YES

NO

35. HAS A COURT AWARDED DAMAGES BASED ON THE DEATH OF THE VETERAN OR IS A CLAIM OR LEGAL ACTION FOR DAMAGES PENDING?
YES

NO

36. HAVE YOU CLAIMED OR ARE YOU RECEIVING SURVIVOR BENEFIT PLAN (SBP) ANNUITY FROM A SERVICE DEPARTMENT BASED ON THE DEATH OF
THE VETERAN?
YES

NO

VA FORM 21P-534, XXX XXXX

Page 5

PART VIII - INCOME AND ASSETS

IMPORTANT: Tell us about the income and assets of you and your dependents.
37A. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?
YES

NO

(If "Yes," complete Item 37B) (If "No," skip to Item 38)

37B. GROSS MONTHLY INCOME (Attach a separate sheet if necessary)

GROSS MONTHLY
AMOUNT

SOCIAL SECURITY RECIPIENT

$
$
$
$
$
$
$
$
$
38. DO YOU OWN YOUR PRIMARY RESIDENCE?
YES

NO

(If "No," skip to Item 40)

39A. WHAT IS THE SIZE OF THE LOT ON WHICH YOUR
PRIMARY RESIDENCE SITS? (Square Feet)
Square Feet:______________

39B. COULD PART OF YOUR LOT BE SOLD WITHOUT SELLING YOUR RESIDENCE?
YES

NO

(If "YES," complete and attach VA Form, 21P-0969, Income and Asset Statement)

IMPORTANT: VA matches income information reported with Federal tax information. Report ALL income you and your dependents
receive on the appropriate sections of this form and VA Form 21P-0969, Income and Asset Statement, if appropriate.
40A. OTHER THAN SOCIAL SECURITY, DO YOU OR YOUR DEPENDENTS
RECEIVE ANY INCOME?
YES

40B. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS RECEIVE
ANY INCOME LAST YEAR?

NO

YES

NO

40C. DO YOU OR YOUR DEPENDENTS HAVE MORE THAN $10,000 IN ASSETS? (NOTE: Assets are all the money and property you or your dependents own. Assets
do not include your primary residence or personal effects such as appliances and vehicles you or your dependents need for transportation)
YES

NO

40D. IN THE THREE CALENDAR YEARS BEFORE THIS YEAR, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS? (Examples of asset transfers include giving
them away, selling them, purchasing an annuity, or using them to establish a trust)
YES

NO

40E. DID YOU ANSWER "YES," TO ANY OF THE QUESTIONS IN ITEMS 40A THRU 40D?
YES

NO

(If "Yes," you must also complete VA Form 21P-0969, Income and Asset Statement)

PART IX - DIRECT DEPOSIT INFORMATION
The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct deposit,
provide the information requested below, and attach either a voided personal check or a deposit slip. If you do not have a bank account, please visit https://www.benefits.
va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking Program (VBBP), and a link to banks and credit unions that may fit
your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must contact representatives handling waiver requests for the Department of the Treasury at
1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.
41. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL
CHECKING
SAVINGS
INSTITUTION OR CERTIFIED PAYMENT AGENT

Account No.:__________________

Account No.:__________________

42. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)

VA Form 21P-534, XXX XXXX

43. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)

Page 6

PART X - MEDICAL, LAST ILLNESS, BURIAL OR OTHER UNREIMBURSED EXPENSES
IMPORTANT: Tell us about medical, last illness, burial or other unreimbursed expenses.
Family medical expenses and certain other expenses actually paid by you may be deductible from your income. Show the amount of any unreimbursed
medical expenses, including the Medicare deduction, you paid over the last year (or expect to pay and continue indefinitely) for yourself or relatives who
are members of your household.
Also, show unreimbursed last illness and burial expenses and educational or vocational rehabilitation expenses you paid. Last illness and burial expenses
are unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the veteran's just debts. Educational or vocational
rehabilitation expenses are amounts paid for courses of education, including tuition, fees, and materials. Do not include any expenses for which you were
reimbursed. If you receive reimbursement after you have filed this claim, promptly advise the VA office handling your claim. If more space is needed attach
a separate VA Form 21P-8416, Medical Expense Report.
IMPORTANT: If you are claiming expenses for in-home care or assisted living, adult day care, or similar facility, you must complete the applicable
worksheet(s) on pages 10 and 11.
44. ARE YOU CLAIMING UNREIMBURSED MEDICAL EXPENSES?
YES

NO

45A. WHOSE MEDICAL,
BURIAL, OR OTHER
EXPENSES WERE PAID?

(If "No," skip to Section XI)
45B. PAID TO
(Name of provider, Insurance
company, nursing home, etc.)

45C. PURPOSE
(Medicare premiums,
nursing home, etc.)

45D. DATE PAID
(mm/dd/yyyy)

45E. HOURLY
RATE/HOURS
(In-home Provider
only)

45F. AMOUNT
YOU PAY

$
$
$
$
$
$
$
$
$
$
$
$

PART XI - CERTIFICATION AND SIGNATURE
I CERTIFY AND AUTHORIZE the release of information:
I CERTIFY that the statements in this document are true and complete to the best of my knowledge. I authorize any person or entity,
including but not limited to any organization, service provider, employer, or government agency, to give the Department of Veterans Affairs
any information about me, and I waive any privilege which makes the information confidential.
46A. SIGNATURE (Provide your signature in the box, DO NOT PRINT) (If you sign with an "X," then you must have 2 people you
know witness as you sign. They must then sign the form and print their names and addresses)

47A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

48A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

VA FORM 21P-534, XXX XXXX

46B. TODAY'S DATE (MM,DD,YYYY)

47B. PRINTED NAME AND ADDRESS OF WITNESS

48B. PRINTED NAME AND ADDRESS OF WITNESS

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PART XII - REMARKS
49. REMARKS (Use this space for any additional information or statements that you would like to make concerning your application)

VA FORM 21P-534, XXX XXXX

Page 8

PART XII - REMARKS (Continued)
49. REMARKS (Continued) (Use this space for any additional information or statements that you would like to make concerning your application)

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 which you are not entitled to.
VA FORM 21P-534, XXX XXXX

Page 9

WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR A SIMILAR FACILITY
NOTE: Only complete this worksheet if you are claiming expenses for an assisted living facility, adult day care or similar facility.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
INSTRUCTIONS: Use this worksheet if you are claiming a disabled person's care in an assisted living facility, adult day care, or similar facility as unreimbursed
medical expenses. Follow the steps below to determine whether VA may deduct all or some of your out-of-pocket payments to the facility.

STEP 1. Are the expenses you wish to claim due to the disabled person's treatment in a hospital, inpatient treatment center,
nursing home, or VA approved
foster
home?
(If "NO,"medical
continue
to Step
2)
YES

NO

(If "YES," all payments to the facility qualify as medical expenses in Items 45A thru 45F. You are finished completing this worksheet)

STEP 2. Do all of the following apply to the facility?
• The facility is licensed (if the State or Country requires it)
• The facility's staff (or the facility's contracted staff) provides the disabled person with
health care or custodial care or both.
• If the facility is residential, it is staffed 24 hours per day with caregivers.
YES

NO (If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)

STEP 3. Are you (the claimant) the disabled person, a surviving spouse, or a Parents' DIC claimant?
YES

NO (If "NO," skip to Step 6)

STEP 4. Did you claim special monthly pension in Item 31?
YES

NO (If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amount you pay the facility for
health care services or assistance with ADLs provided by a health care provider in Items 45A thru 45F. Skip to Step 8)

STEP 5. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care.
Is this the primary reason you live in the facility (or attend day care in the facility)?

YES

NO

(If "YES," all payments to this facility may qualify as medical expenses in Items 45A thru 45F if VA rates you as eligible for special monthly
pension or special monthly DIC. Please report separately in Items 45A - 45F applicable amounts you pay the facility for (1) lodging and
meals; (2) health care services or assistance with ADLs provided by a health care provider; and (3) custodial care. Skip to Step 8)
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Please report separately in Items 45A thru 45F
applicable amounts you pay the facility for: (1) health care services or assistance with ADLs provided by a health care provider
and (2) custodial care. Skip to Step 8)

STEP 6. Does the disabled person require the health care services or custodial care that the facility provides to him or her because of the disabled
person's mental or physical disability?

YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care services
or custodial care that the facility provides to him or her because of mental or physical disability, and (2) describes the mental or physical
disability)
(If "NO," claim only amounts you pay the facility for health care services or assistance with ADLs provided by a health care provider in
Items 45A thru 45F. Skip to Step 8)

STEP 7. If you answered "YES" in Step 2, you stated that the facility provides the disabled person with health care and/or custodial care.
Is this the primary reason the disabled person lives in the facility (or attends day care in the facility)?
(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Items 45A thru 45F)
YES

NO

(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for
health care services or custodial care in Items 45A thru 45F)

STEP 8. Facility Certification (Please submit a current statement showing the fees the claimant pays to your facility and a breakdown of the care
received)
I CERTIFY the information stated within this WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________
(Name of individual staying at your facility)

and his/her care at this facility (_________________________________________________________________________________________________).
(Name and address of facility)

__________________________________________________________________
(Name, Signature, Title at Facility)

VA FORM 21P-534, XXX XXXX

___________________
(Date)

Page 10

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
IMPORTANT: The following activities are examples of Instrumental Activities of Daily Living (IADLs) for VA purposes. VA generally does not recognize assistance
with these activities as medical expenses: (1) Shopping; (2) Food Preparation; (3) Housekeeping; (4) Laundering; (5) Handling medications; (6) Using the telephone;
(7) Transportation (except for medical purposes such as transportation to a doctor's appointment).
INSTRUCTIONS: Use this worksheet if you are claiming payments to a disabled person's in-home attendant as an unreimbursed medical expense.
Follow the steps below to determine whether or not:
• the attendant must be a health care provider for VA purposes and
• VA may deduct payment for assistance with IADLs as well as assistance with ADLs and custodial care.

STEP 1. Are you (the claimant) the disabled person, a surviving spouse, or Parents' DIC claimant?
YES

NO

(If "NO," skip to Step 4)

STEP 2. Did you claim special monthly pension on Item 31?
YES

NO

(If "NO," the in-home attendant must be a health care provider and payments for assistance with IADLs do not qualify as medical
expenses. Payments for health care services or custodial care qualify as medical expenses. You may claim these expenses in Items
45A thru 45F. Skip to Step 6)

STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?

YES

NO

(If "YES," payments to this in-home attendant may qualify as medical expenses if VA rates you as eligible for special monthly pension.
Please report separately in Items 45A - 45F amounts you pay an in-home attendant for: (1) health-care services or assistance with ADLs
provided by a health care provider; (2) assistance with IADLs, and (3) custodial care. Skip to Step 6)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Items 45A thru 45F applicable amounts you pay an in-home attendant for: (1) health care services or assistance with
ADLs provided by a health care provider; and (2) custodial care. Skip to Step 6)

STEP 4. Does the disabled person require the health care services or custodial care that the in-home attendant provides to him or her because of the
disabled person's mental (If
or"YES,"
physical
disability?
you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care
NO

YES

services or custodial care that the in-home attendant provides the disabled person because of the disabled person's mental or physical
disability, and (2) describes the mental or physical disability)
(If "NO," the attendant must be a health care provider. Only report payments to the in-home attendant for health care services or
assistance with ADLs provided by the health care provider as medical expenses in Items 45A thru 45F. Payments for assistance with
IADLS do not qualify as medical expenses. Skip to Step 6)

STEP 5. Is the primary responsibility of the in-home attendant to provide the disabled person with health care or custodial care?
YES

NO

(If "YES," payments to the in-home attendant qualify as medical expenses (even assistance with IADLs) and can be reported in
Items 45A thru 45F)
(If "NO," report payments to this in-home attendant for health care and/or custodial care as medical expenses in Items 45A thru 45F.
Payment for assistance with IADLs do not qualify as medical expense)

STEP 6. Check all activities below with which the attendant assists the disabled person:
DRESSING
EATING
BATHING/SHOWERING
ADLs:

TRANSFERRING

USING THE TOILET

IADLs:

LAUNDERING

MANAGING FINANCES

SHOPPING

HOUSEKEEPING

FOOD PREPARATION

HANDLING MEDICATIONS

USING THE TELEPHONE

TRANSPORTANTION (FOR NON-MEDICAL PURPOSES)

STEP 7. In-Home Attendant Certification (Please submit a breakdown of the time the attendant spends assisting the disabled person with health care
services, ADLs, and IADLs.)
I CERTIFY the information within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and reflects the current environment
pertaining to _______________________________________________________________________________________ and his/her care
(Name of Individual Requiring Care)

from (_________________________________________________________________________________________________).
(Name of Attendant)

__________________________________________________________________
(Name, Signature, Title)

VA Form 21P-534, XXX XXXX

___________________
(Date)

Page 11

Form Approved
OMB Approved No. 0960-0062

SOCIAL SECURITY ADMINISTRATION

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

APPLICATION FOR SURVIVORS BENEFITS

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)
IMPORTANT - Read instructions before completing form. Detach and retain ONLY the instruction sheet.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.
3. SOCIAL SECURITY NO. OF VETERAN

4. DATE OF BIRTH

5. PLACE OF BIRTH
8. DID THE VETERAN WORK IN THE RAILROAD
INDUSTRY AT ANY TIME AFTER 1936?

7. MAIDEN NAME OF MOTHER

6. NAME OF FATHER

YES

NO

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the
military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric
Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.
9A. DATE ENTERED ACTIVE SERVICE

9B. SERVICE NO.

10. RELATIONSHIP OF APPLICANT TO VETERAN
PARENT
SURVIVING SPOUSE
CHILD

9C. DATE SEPARATED FROM ACTIVE
SERVICE

11. DATE OF BIRTH OF APPLICANT

9D. GRADE, RANK, OR RATING, ORGANIZATION
AND BRANCH OF SERVICE

12. VA FILE NO.

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including step
grandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c)
disabled or handicapped (18 or over and disability began before age 22).
13A.

13B.

13C.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a
right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I
have given in this document is true.
14. DATE (Month, day, year)

15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code)

17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)

20. PROOFS RECEIVED
DEATH

MARRIAGE

AGE

DEATH

(NAME)

OTHER (Specify)

(NAME)

AGE
OTHER (Specify)

(NAME)
22. DATE

MARRIAGE

(NAME)
(NAME)
(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (2-2002) Destroy All Prior Editions

Page 12

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)

This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the
Social Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the
application requests information in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete
part or all of the SSA-24. However, it is usually to your advantage to provide the information because not
providing it could prevent an accurate and timely decision on your claim or could result in the loss of
some benefits or insurance coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to
the Social Security Administration and used by them to determine whether social security benefits may be
payable to surviving dependent(s) of the veteran. Social Security will then contact you regarding any
social security benefits payable based on information given on this form.
Please understand that Social Security may, in certain instances, disclose the information on this form to
another Federal, State or local agency or individual without your written consent. This would be done in
order to:
enable a third party or an agency to assist Social Security in establishing an individual's
right to benefits or coverage;
comply with Federal laws which require or authorize the release of information from social
security records; and
facilitate statistical research and audit activities necessary to assure the integrity and
improvement of the social security programs.
If you should have any question about entitlement to social security benefits or the information you have
provided on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When
signed and dated the form SHOULD BE LEFT ATTACHED to your completed
VA Form 21P-534, Application for Dependency and Indemnity Compensation, Death Pension a
and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if
Applicable) or
VA Form 21P-535, Application for Dependency and Indemnity Compensation by Parent(s)
(Including Accrued Benefits and Death Compensation When Applicable).
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of
44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required
to answer these questions unless we display a valid Office of Management and Budget control number.
We estimate that it will take you about 15 minutes to read the instructions, gather the necessary facts, and
answer the questions.

Form SSA-24 (2-2002) Destroy All Prior Editions

Page 13