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

OMB Control No. 2900-0469
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX
1. INSURANCE POLICY NUMBER (This applies to all
policies under named veteran unless otherwise noted)

CERTIFICATE SHOWING RESIDENCE AND HEIRS OF
DECEASED VETERAN OR BENEFICIARY

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

3. SOCIAL SECURITY NUMBER OF INSURED

USE OF THIS FORM - PLEASE READ BEFORE COMPLETING
This form used is to provide information concerning the heirs of a deceased Veteran or beneficiary and is typically used
when an estate is entitled, or payment is made by a set order of individuals defined by law (order of precedence). Order
of precedence is defined as payment made in the following order:
1) Surviving spouse,
2) Children and decedents of deceased children,
3) Parents or their surviving children (Veteran’s Siblings),
4) The duly appointed executor or administrator of my estate,
5) Other next of kin based upon the laws of the Veteran’s residence (domicile) at time of death.
Some examples of when this form is used include:
•
•
•
•

The Veteran designates their estate as a beneficiary, or
All designated beneficiaries die before the Veteran and payment is either made to the estate or by law, or
There is no beneficiary designation on record, or
A beneficiary dies more than 120 hours after the Veteran, and the proceeds of the insurance are payable
to the beneficiary’s estate, or
• The Veteran elected the insurance payable order of precedence
GENERAL INSTRUCTIONS FOR COMPLETING THIS FORM
• You may either complete the form online or by hand. If completed by hand, print the information requested in ink,
neatly, and legibly, using capital letters to expedite processing of the form.
• Follow the instructions throughout the form in completing each block.
• If there is not enough space to annotate all heirs in the appropriate boxes, please use Block 13 or attach a sheet of
paper clearly documenting the additional heirs. Make sure you include their name, relationship, age, date of death
(if applicable), parentage, and contact information. Please include your name, signature, and date on the attached
page.
• This form must be completed correctly and in full to prevent any delay in payment.
SECTION I - COMPLETE ITEMS 4A-4C WHEN PAYMENT WILL BE MADE TO THE VETERAN’S ESTATE, HEIRS, OR BY ORDER
OF PRECEDENCE. NOTE: IF PAYMENT WILL BE MADE TO THE BENEFICIARY’S ESTATE, SKIP TO ITEM 5A.
4A. VETERAN’S NAME (First, Middle, Last)

4B. ARE THERE HEIRS TO THE VETERAN'S ESTATE?

YES

NO

4C. HAS THERE BEEN OR WILL THERE BE A COURT- APPOINTED EXECUTOR OR ADMINISTRATOR FOR THE VETERAN’S ESTATE?

YES

NO

NOTE: A court-appointed executor or administrator is a person who is formally appointed by a probate court to administer a deceased
person’s estate. If there is a formally appointed executor or administrator, then select yes. If none, then select no.
If there is a court appointed executor or administrator appointed for the estate, the executor or administrator must furnish letters
testamentary or letters of administration.

VA FORM
XXX XXXX

29-541

SUPERSEDES VA FORM 29-541, AUG 2022,
WHICH WILL NOT BE USED.

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SECTION II - COMPLETE ITEMS 5A-5C WHEN PAYMENT WILL BE MADE TO THE BENEFICIARY'S ESTATE
5A. BENEFICIARY’S NAME (First, Middle, Last)

5B. ARE THERE HEIRS TO THE BENEFICIARY'S ESTATE?

YES

NO

5C. HAS THERE BEEN OR WILL THERE BE A COURT- APPOINTED EXECUTOR OR ADMINISTRATOR FOR THE BENEFICIARY'S ESTATE?

YES

NO

NOTE: A court-appointed executor or administrator is a person who is formally appointed by a probate court to administer a deceased
person’s estate. If there is a formally appointed executor or administrator, then select yes. If none, then select no.
If there is a court appointed executor or administrator appointed for the estate, the executor or administrator must furnish letters
testamentary or letters of administration.
SECTION III - INFORMATION REGARDING VETERAN'S OR BENEFICIARY'S RESIDENCE
6. PROVIDE THE STATE OF RESIDENCE (VETERAN OR BENEFICIARY) AT TIME OF DEATH

SECTION IV - INFORMATION REGARDING HEIRS OF THE VETERAN'S OR BENEFICIARY'S ESTATE
IMPORTANT: - Write the word "NONE" in each item where there is no next of kin. Write “DO NOT KNOW” for any item where information is unknown to
the individual completing this form. If additional space is required, attach a separate sheet, or use the remarks block. If additional sheets are necessary,
each sheet must be signed.
7. IDENTIFYING INFORMATION REGARDING SPOUSE OF DECEASED VETERAN/BENEFICIARY
B. AGE

A. NAME OF SPOUSE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH
(If deceased) (MM/DD/YYYY)

E. YEAR OF
MARRIAGE
(YYYY)

8. IDENTIFYING INFORMATION REGARDING ALL CHILDREN OF DECEASED VETERAN/BENEFICIARY

INSTRUCTIONS

Item 8A: Please include list of biological, natural born, adopted, deceased, and stepchildren. Provide the relationship to the Veteran or
beneficiary in this Item (i.e., John Smith, adopted).
Item 8B: Provide current age of child named in Item 8A.
Item 8C: Provide current address, phone number, and email for child named in Item 8A.
Item 8D: If applicable, provide date of death of child named in Item 8A. Otherwise, leave blank.
Item 8E: Provide the names of the parents of the child(ren) listed in Item 8A.
Example: The Veteran (Michael Smith) has a child named John Smith, John Smith’s parents are Michael and Jane Smith. Michael and Jane Smith
would be listed in Item 8E.
NOTE: If more space is needed, please use Item 13. Additional pages can be used if needed, please include your name, signature and date
on the attached page.
A. NAME(S) OF CHILD(REN)

(Include illegitimate, adopted, deceased,
unborn child, and stepchild)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF
DEATH (If deceased)
(MM/DD/YYYY)

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

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
VA FORM 29-541, XXX XXXX

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SECTION IV - INFORMATION REGARDING HEIRS OF THE VETERAN'S OR BENEFICIARY'S ESTATE (Continued)
9. IDENTIFYING INFORMATION REGARDING ALL GRANDCHILD(REN) OF DECEASED VETERAN/BENEFICIARY

INSTRUCTIONS

Item 9A: Please include list of biological, natural born, adopted, deceased, and step-grandchild. Provide the relationship to the Veteran or
beneficiary in this Item (i.e., John Smith, adopted).
Item 9B: Provide current age of grandchild named in Item 9A.
Item 9C: Provide current address, phone number, and email for grandchild named in Item 9A.
Item 9D: If applicable, provide date of death of grandchild named in Item 9A. Otherwise, leave blank.
Item 9E: Provide the names of the parents of the granchild listed in Item 9A.
Example: The Veteran (Michael Smith) has a child named John Smith, John Smith’s parents are Michael and Jane Smith. Michael and Jane Smith
would be listed in Item 9E.
NOTE: If more space is needed, please use Item 13. Additional pages can be used if needed, please include your name, signature and date
on the attached page.
A. NAME(S) OF GRANDCHILD(REN)
(Include illegitimate, adopted, deceased,
unborn child, and step-grandchild)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF
DEATH (If deceased)
(MM/DD/YYYY)

E. PARENTS OF
GRANDCHILD(REN) NAMED
IN ITEM 7A

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
10. IDENTIFYING INFORMATION REGARDING PARENTS OF DECEASED VETERAN/BENEFICIARY
A. NAME OF PARENT(S)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH (If deceased)
(MM/DD/YYYY)

PARENT

PARENT

IMPORTANT: If spouse, child(ren), or parent(s) survive the VETERAN/BENEFICIARY, skip to Item 14.
11. IDENTIFYING INFORMATION REGARDING BROTHER(S) AND SISTER(S) OF DECEASED VETERAN/BENEFICIARY

IMPORTANT: STATE UNDER THE NAME IN 11A WHETHER FULL SIBLING, HALF SIBLING, OR ADOPTED SIBLING
NOTE: This form allows you to list 6 siblings of the person named in 4A or 5A. If more space is needed, please use Item 13.
Additional pages can be used if needed, and must include your name, signature, and date on the attached page.
A. NAME(S) OF BROTHER(S) AND
SISTER(S)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH (If deceased)
(MM/DD/YYYY)

Name:
Relationship:
Name:
Relationship:
VA FORM 29-541, XXX XXXX

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11. IDENTIFYING INFORMATION REGARDING BROTHER(S) AND SISTER(S) OF DECEASED VETERAN/BENEFICIARY (Continued)
A. NAME(S) OF BROTHER(S) AND
SISTER(S)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF DEATH (If deceased)
(MM/DD/YYYY)

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
12. IDENTIFYING INFORMATION REGARDING CHILDREN OF DECEASED BROTHER(S) AND SISTER(S)

NOTE: This section allows you to list 6 descendants of any deceased siblings (nieces and nephews) listed in block 10. If more space
is needed, use Item 13. Additional pages can be used if needed, but please include your name, signature, and date on the attached
page.
Item 12E: Provide the names of the parents of the child(ren) listed in Item 12A.
Example: The Veteran had a sibling named Jane Doe, who has a child named John Doe, John Doe’s parents are Jane Doe and
Richard Doe. Jane and Richard Doe would be listed in Item 12E.
A. NAME(S) OF CHILD(REN)
OF DECEASED BROTHER(S)
AND SISTER(S)

B. AGE

C. ADDRESS / PHONE NUMBER / EMAIL

D. DATE OF
DEATH (If deceased)
(MM/DD/YYYY)

E. PARENTS OF
CHILD(REN) NAMED IN ITEM
12A

Name:

Name:

Name:

Name:

Name:

Name:

Name:

SECTION V - ADDITIONAL INFORMATION
(Use this section for information regarding additional heirs. Please include their name, relationship,
age, date of death (if applicable, parentage, and contact information)
13. PROVIDE INFORMATION FOR ANY ADDITIONAL HEIRS

VA FORM 29-541, XXX XXXX

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13. PROVIDE INFORMATION FOR ANY ADDITIONAL HEIRS (Continued)

SECTION VI - CERTIFICATION AND SIGNATURE
I CERTIFY THAT to the best of my knowledge and belief, the above named are the only relatives of the veteran/beneficiary, living or
dead, and that the foregoing statements are true.
14A. NAME (FIRST, MIDDLE, LAST)

14B. DAYTIME TELEPHONE NUMBER (Include Area Code)

14C. RELATIONSHIP TO DECEASED

14D. 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/.

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

PRIVACY 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: 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 2900-0469, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 30 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. 2900-0469 in any correspondence. Do not send your completed VA Form 29-541 to this email address.
VA FORM 29-541, XXX XXXX

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