21P-4171 Supporting Statement Regarding Marriage

OMB Control No. 2900-0115
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP
(DO NOT WRITE IN THIS
SPACE)

SUPPORTING STATEMENT REGARDING MARRIAGE
Privacy Act Notice: 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 obligation to respond is voluntary. 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 2900-0115, 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. 2900-0115 in any
correspondence. Do not send your completed VA Form 21P-4171 to this email address.

INSTRUCTIONS: Please complete all items. Your answer to every question is important to help us complete the claimant's claim. If you do not know the
answer, write "unknown." For additional space, use Item 17, "Remarks," or attach a separate sheet, indicating the item number to which the answers apply.
See page 2 for mailing information.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
2B. VA FILE NUMBER (If applicable)

2A. VETERAN'S SOCIAL SECURITY NUMBER

C/CSS3. CLAIMED SPOUSE OR SURVIVING SPOUSE'S NAME (First, Middle Initial, Last)
4A. NAME OF PERSON COMPLETING THIS FORM (First, Middle Initial, Last)
4B. ADDRESS OF PERSON COMPLETING THIS FORM (Number and street, P.O. or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

5A. WHAT WAS/IS YOUR RELATIONSHIP
TO THE VETERAN? (Parent, child,
brother, sister, etc. If not related, state
"None")

ZIP Code/Postal Code

5B. WHAT WAS/IS YOUR
6A. HOW LONG HAD/HAVE
6B. HOW LONG HAD/HAVE
RELATIONSHIP TO THE CLAIMED
YOU KNOWN THE
YOU KNOWN
SPOUSE? (Parent, child, brother, sister,
VETERAN? (Months,years)
THE CLAIMED
etc. If not related, state "None")
SPOUSE? (Months, years)

7A. HOW OFTEN HAD/HAVE YOU VISITED THE VETERAN?

7B. ON WHAT OCCASION(S) HAD/HAVE YOU VISITED THE VETERAN?

7C. HOW OFTEN HAD/HAVE YOU VISITED THE CLAIMED SPOUSE?

7D. ON WHAT OCCASIONS HAVE YOU MET THE CLAIMED SPOUSE?

8. WERE/ARE THE VETERAN AND THE CLAIMED SPOUSE
GENERALLY KNOWN AS MARRIED?

9. DID/DO EITHER THE VETERAN OR CLAIMED SPOUSE EVER DENY
THE MARRIAGE?

YES

YES

NO

10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMED
SPOUSE TO BE MARRIED?
YES

NO

NO

10B. PROVIDE FACTS AND REASONS FOR SUCH BELIEF (If additional
space needed use Item 17, "Remarks" )

(If "Yes," complete Item 10B)
11. NAME(S) BY WHICH SPOUSE WAS/IS KNOWN
FIRST NAME

LAST NAME

12A. HAD/HAVE YOU EVER HEARD THE VETERAN OR THE CLAIMED SPOUSE REFER TO EACH OTHER AS MARRIED TO ONE ANOTHER?
(If "Yes," complete Items 12B and 12C)
YES
NO
12B. DATE (MM/DD/YYYY)

VA FORM
XXXX

21P-4171

12C. PLACE

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VETERAN'S SOCIAL SECURITY NO.

13A. DID/DO THE VETERAN AND THE CLAIMED SPOUSE MAINTAIN A HOME AND LIVE TOGETHER AS MARRIED TO ONE ANOTHER?
(If "Yes," complete Item 13B)
YES
NO
13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMED SPOUSE HAD/HAVE LIVED TOGETHER
BEGINNING DATE
ENDING DATE
STATE
CITY OR TOWN
(MM/DD/YYYY)
(MM/DD/YYYY)

14A. HAD/HAVE THE VETERAN AND THE CLAIMED SPOUSE LIVED TOGETHER CONTINUOUSLY?
(If "Yes," complete Item 14B)
YES
NO
14B. EXPLANATION

15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 15B)
YES
NO
15B. OTHER MARRIAGES OF VETERAN
TO WHOM MARRIED

DATE (MM/DD/YYYY) AND
PLACE OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE ENDED

(Death, divorce, etc.)

DATE (MM/DD/YYYY) AND
PLACE MARRIAGE ENDED

16A. HAS THE CLAIMED SPOUSE EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 16B)
YES
NO
16B. OTHER MARRIAGES OF CLAIMED SPOUSE
TO WHOM MARRIED

DATE (MM/DD/YYYY) AND
PLACE OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE ENDED

(Death, divorce, etc.)

DATE (MM/DD/YYYY) AND
PLACE MARRIAGE ENDED

17. REMARKS (If any)

CERTIFICATION
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief. I understand that this statement will be considered in
connection with an application for VA benefits based on a marital relationship between the veteran and the person named in Item 3.
18A. SIGNATURE (Sign in ink)

18B. DATE SIGNED (MM/DD/YYYY)

18C. DAYTIME TELEPHONE NUMBER (Including Area Code)

18D. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESS TO SIGNATURE IF MADE BY "X" MARK

NOTE: Signature by mark must be witnessed by two persons to whom the signer is personally known and the signature and addresses of the witnesses must be entered below.

19A. SIGNATURE OF WITNESS (Sign in ink)

19B. ADDRESS OF WITNESS

20A. SIGNATURE OF WITNESS (Sign in ink)

20B. ADDRESS OF WITNESS

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.
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.

MAIL TO: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365
VA FORM 21P-4171, XXXX

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