VA Form 21P-8924 Application of Surviving Spouse or Child for REPS (Resto

OMB Approved No. 2900-0390
Respondent Burden: 20 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION OF SURVIVING SPOUSE OR CHILD
FOR REPS BENEFITS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden information on
page 3. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000.
If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.

SECTION I - VETERAN'S INFORMATION

NOTE: You may complete the form on-line or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and completely fill in each applicable
circle to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

5. DATE OF DEATH (MM/DD/YYYY)

4. BRANCH OF SERVICE

ARMY

NAVY

SPACE FORCE

COAST GUARD

MARINE CORPS

AIR FORCE

OTHER (Specify)

SECTION II - CLAIMANT'S INFORMATION

6. NAME OF CLAIMANT (First, Middle Initial, Last) (SEE INSTRUCTIONS)

8. SOCIAL SECURITY NUMBER

7. DATE OF BIRTH (MM,DD,YYYY)

9. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code and Country)

Street address, rural route, or P.O. Box

City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

10. TELEPHONE NUMBER (Include Area Code)

11. E-MAIL ADDRESS (If applicable)

Enter International Phone Number
(If applicable)
12. RELATIONSHIP TO VETERAN
SPOUSE

13. MARITAL STATUS
MARRIED

SINGLE

CHILD

14. DATE OF MARRIAGE (MM/DD/YYYY)

DIVORCED/WIDOWED (If checked, complete Items 14 and 15

15. DATE MARRIAGE TERMINATED

SECTION III - CLAIMANT'S EMPLOYMENT AND WAGE INFORMATION

(To be completed in full, only if you are a surviving spouse, and the youngest child in your care has reached age 16, but is not yet 18)
16. EMPLOYMENT STATUS (PLEASE SELECT ONE)

17. TOTAL EARNINGS FROM EMPLOYMENT FOR LAST CALENDAR YEAR

EMPLOYED
SELF EMPLOYED (Enter number of hours worked per month):

$

.00

NOT EMPLOYED
18. MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR THIS
CALENDAR YEAR? (You must enter an estimate)

$

.00

19. MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR NEXT
CALENDAR YEAR? (You must enter an estimate)

$
(Year)

VA FORM
XXX XXXX

21P-8924

(Year)

SUPERSEDES VA FORM 21P-8924, MAR 2018,
WHICH WILL NOT BE USED.

.00
(Year)
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SECTION IV - REMARKS
20. REMARKS (If any)

SECTION V - CERTIFICATION AND SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN
I CERTIFY THAT the statements provided are true and correct to the best of my knowledge.
21. SIGNATURE OF CLAIMANT, CUSTODIAN, OR GUARDIAN (REQUIRED)

22. DATE SIGNED
Month

Day

Year

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 to which you are not entitled.

SECTION VI - CERTIFICATION OF SERVICE-CONNECTION OR DEATH ON ACTIVE DUTY
I HEREBY CERTIFY THAT the deceased died on active duty prior to August 13, 1981, or died from a service-connected disability incurred
or aggravated prior to August 13, 1981.

23A. SIGNATURE AND TITLE OF VA OFFICIAL

23B. VARO (City) AND STATION NUMBER

23C. DATE SIGNED
Month

VA FORM 21P-8924, XXX XXXX

Day

Year

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INFORMATION
WHO IS ELIGIBLE: Benefits are payable to certain survivors of members or former members of the Armed
Forces who died while on active duty prior to August 13, 1981, or who died from a disability incurred in or
aggravated by active duty prior to August 13, 1981. Service in the Public Health Service or National Oceanic
and Atmospheric Administration does not qualify.
SURVIVING SPOUSE: If you were married to the veteran at the time of his or her death and are not currently
married, you may be eligible for REPS benefits for yourself when the youngest child in your care reaches age
16. These benefits will terminate when the child reaches age 18, whether or not the child is still in high school.
CHILD: If you are an unmarried child of the veteran between the ages of 18 and 21 and are attending a
postsecondary school full time, you may be eligible for REPS. In the United States, "postsecondary school"
refers to school above the level of high school. If you are age 18 and still in high school, you are not eligible for
REPS. However, you may apply to the Social Security Administration for an extension of benefits.
INSTRUCTIONS
If you are applying as a surviving spouse whose youngest child in care is age 16 or 17, please complete
Section II-Claimant's Information. All other questions on the form pertain to you and not to your child. If you are
the veteran's child, age 18 to 21 and attending college or other postsecondary school full time, please
complete Section II-Claimant's Information. All other questions on this form pertain to you.
NOTE: This form is intended to serve as an application for only one person. Additional forms can be obtained
from the internet at www.va.gov/vaforms.
NOTE: Action on your claim may be delayed if you do not provide all of the information requested. You are
required to estimate wage information in Part III, even if you do not know the exact wage amount(s). If you
need additional space, use Item 20, "REMARKS", or attach a separate sheet and label your answers to
correspond to the question numbers on the form. Please include the veteran's full name and VA file number on
each sheet. Please type or print in ink.
The form should be returned to VA by mail at the address shown below:
VA Regional Office,
400 S. 18th St.,
St. Louis, MO 63103-2271
IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGES IN THE INFORMATION PROVIDED ON THIS APPLICATION.
To report any changes, please contact the VA National Call Center via telephone at 1-800-827-1000.

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 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 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. 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this project is 2900-0390, and it expires XX/XX/20XX. Public
reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden,
to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0390 in any correspondence. Do
not send your completed VA Form 21P-8924 to this email address.

VA FORM 21P-8924, XXX XXXX

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