Form 21-4170 Statement of Marital Relationship

OMB Control No. 2900-0114
Respondent Burden: 25 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

STATEMENT OF MARITAL RELATIONSHIP
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on Page 4. Use this form
to provide information to VA to determine your marital status. 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. VA forms are available at www.va.gov/vaforms. See mailing information on page 5.
IMPORTANT INFORMATION: This form is to be completed by the veteran (if living) and the person who is claiming to be the spouse or surviving spouse
of the veteran. Note: For the purposes of this form, the person who is claiming to be the spouse or surviving spouse of the veteran is referred to as such.
If you do not know the answer, write "unknown". Submit any documents that show your marital status as holding yourselves out as married or whether
you are generally accepted as such in the community in which you live or lived. For example, lease agreements, joint bank statements, utility bills, tax
returns, insurance forms, employment records, and any other documents showing marital status. Be advised that original documents will not be returned
to you. We highly encourage you to submit certified copies instead. If additional space is needed, use Section VI: Remarks, indicating the item number to
which the answers apply.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, insert one letter per
box, 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 (If applicable)

5. SERVICE NUMBER (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

4. DATE OF BIRTH (MM/DD/YYYY)

Enter International Phone Number (If applicable)

SECTION II - SPOUSE OR SURVIVING SPOUSE'S IDENTIFICATION INFORMATION
7. NAME OF SPOUSE OR SURVIVING SPOUSE (First, Middle Initial, Last)

8. SOCIAL SECURITY NUMBER OF SPOUSE OR
SURVIVING SPOUSE

9. DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE (MM/DD/YYYY)

10. MAILING ADDRESS OF VETERAN OR CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

SECTION III - INFORMATION ABOUT THE MARITAL RELATIONSHIP CLAIMED
11A. DATE YOU BEGAN LIVING AS MARITAL
PARTNERS (MM/DD/YYYY)

11B. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS MARITAL PARTNERS
(First, Middle Initial, Last)

11C. PLACE YOU BEGAN LIVING AS MARITAL PARTNERS (Include number and street or rural route, city or P. O., state and ZIP Code)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

NOTE - ITEMS 11D THROUGH 13 ARE TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE.
11D. AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?

ALWAYS

SOMETIMES

NEVER

11E. WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE TIME YOU BEGAN LIVING TOGETHER? (Explain below)

11F. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?
YES
VA FORM
XXX XXXX

NO

(If "YES," skip to Item 13)( If "NO," complete Item 12)

21-4170

SUPERSEDES VA FORM 21-4170, JUL 2021.

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VETERAN'S SOCIAL SECURITY NUMBER

12. LIST ALL PERIODS OF SEPARATION
FROM: BEGINNING DATE
(MM/DD/YYYY)

TO: ENDING DATE
(MM/DD/YYYY)

REASON FOR SEPARATION

13. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS MARITAL PARTNERS
FROM: BEGINNING DATE
(MM/DD/YYYY)

TO: ENDING DATE
(MM/DD/YYYY)

ADDRESS (Street address, city, and state)

SECTION IV - INFORMATION ABOUT YOUR CHILDREN

IMPORTANT INFORMATION: Send a certified copy of the public record of birth for each child listed in Item 14B.
14A. HAVE YOU HAD CHILDREN TOGETHER?
YES

NO

(If "Yes," complete Item 14B) (If "No," skip to Item 15A)

14B. FULL NAME OF CHILD (First, Middle Initial, Last)

14C. PLACE OF BIRTH (City/State or Country)

SECTION V - INFORMATION ABOUT YOUR MARITAL HISTORY

INSTRUCTIONS: Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional
space, use Section VI: Remarks.
IMPORTANT INFORMATION: Attach copies of divorce decrees.
15A. HAS (HAD) THE VETERAN EVER LIVED WITH ANOTHER PERSON AS A MARITAL PARTNER?
YES

NO

(If "YES," complete Items 15B through 15M) (If "No," skip to Item 16A)

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VETERAN'S SOCIAL SECURITY NUMBER

15B. DATE OF MARRIAGE
(MM/DD/YYYY)

15C. PLACE
(City/State or Country)

15D. TO WHOM MARRIED
(First, Middle Initial, Last)

15E. DATE MARRIAGE ENDED
(MM/DD/YYYY)

15F. PLACE
(City/State or Country)

15G. HOW MARRIAGE ENDED
(Death,
divorce, etc.)

15H. DATE OF MARRIAGE
(MM/DD/YYYY)

15I. PLACE
(City/State or Country)

15J. TO WHOM MARRIED
(First, Middle Initial, Last)

15K. DATE MARRIAGE ENDED
(MM/DD/YYYY)

15L. PLACE
(City/State or Country)

15M. HOW MARRIAGE ENDED
(Death,
divorce, etc.)

16A. HAS THE SPOUSE OR SURVIVING SPOUSE EVER LIVED WITH ANOTHER PERSON AS A MARITAL PARTNER?
YES

NO

(If "Yes," complete Item 16B through 16M) (If "No," skip to Item 17)

16B. DATE OF MARRIAGE
(MM/DD/YYYY)

16C. PLACE
(City/State or Country)

16D. TO WHOM MARRIED
(First, Middle Initial, Last)

16E. DATE MARRIAGE ENDED
(MM/DD/YYYY)

16F. PLACE
(City/State or Country)

16G. HOW MARRIAGE ENDED
(Death,
divorce, etc.)

16H. DATE OF MARRIAGE
(MM/DD/YYYY)

16I. PLACE
(City/State or Country)

16J. TO WHOM MARRIED
(First, Middle Initial, Last)

16K. DATE MARRIAGE ENDED
(MM/DD/YYYY)

16L. PLACE
(City/State or Country)

16M. HOW MARRIAGE ENDED
(Death,
divorce, etc.)

SECTION VI - REMARKS
17. REMARKS (If any)

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VETERAN'S SOCIAL SECURITY NUMBER
17. REMARKS (Continued)

SECTION VII - CERTIFICATION AND SIGNATURE(S)

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.
18A. SIGNATURE OF VETERAN (REQUIRED)

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

19A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE (REQUIRED)

19B. DATE SIGNED (MM/DD/YYYY)

SECTION VIII - WITNESSES TO SIGNATURE(S) IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the veteran or the claimed spouse or surviving spouse is personally known and the signatures
and addresses of the witnesses must be entered below.
20B. ADDRESS OF WITNESS (Number and street or rural route, P.O. Box, City, State and ZIP Code)
20A. SIGNATURE OF WITNESS (REQUIRED)

21A. SIGNATURE OF WITNESS (REQUIRED)

21B. ADDRESS OF WITNESS (Number and street or rural route, P. O. Box, City, State and ZIP Code)

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.
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 obligation to respond 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). 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. 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: 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 2900-0114, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 25 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. 2900-0114 in any correspondence. Do not send your completed VA Form 21-4170 to this email address.
VA FORM 21-4170, XXX XXXX

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WHERE TO SEND YOUR WRITTEN CORRESPONDENCE
Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA
recommends submitting correspondence electronically as this is the fastest method of receipt.
VA provides several tools to assist in electronic submission. To learn more about how to submit documents and
claims electronically, visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to
access.va.gov to digitally upload any correspondence using Direct Upload.
By visiting www.va.gov you can also check your claims status and learn about other VA benefits.
If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the related mailing address below.
COMPENSATION CLAIMS
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

FIDUCIARY
Department of Veterans Affairs
Fiduciary Intake
PO Box 95211
Lakeland, FL 33804-5211

PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

BOARD OF VETERANS' APPEALS
Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038

These addresses serve all United States and foreign locations.

VA FORM 21-4170, XXX XXXX

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