Form 21P-0847 Request for Substitution of Claimant upon Death of Claim

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE REQUEST FOR
SUBSTITUTION OF CLAIMANT UPON DEATH OF CLAIMANT
GENERAL INFORMATION
38 U.S.C. section 5121a, Substitution in case of death of claimant. It provides that if a claimant dies while a claim
or appeal for any benefit under a law administered by the Secretary is pending, a living person who would be
eligible to receive accrued benefits due to the claimant under section 5121(a) of this title may, not later than one
year after the date of the death of the claimant, request to be substituted as the claimant for the purposes of
processing the claim to completion.
The new statute allows a person who could be considered an accrued benefits claimant to substitute for a
deceased claimant to continue adjudication of the deceased claimant's claim.
SPECIFIC INSTRUCTIONS
Section 1
In this section, give us the pertinent identifying information of the deceased veteran and/or deceased claimant
including name, claim and/or social security numbers, and date of birth.
Section 2
Provide us with the substituting claimants' pertinent contact information to include name, address, contact
numbers, and mail address.
Where Do I Send My Completed Form?
Please mail the completed form to:
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547-5365
NOTE: You should make a copy of your signed authorization for your records before mailing it to VA.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want to be the substitute for the deceased claimant, write us a letter to
revoke your request.

VA FORM
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OMB Approved No. 2900-0740
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

REQUEST FOR SUBSTITUTION OF CLAIMANT UPON
DEATH OF CLAIMANT
INSTRUCTIONS: Use this form if you want to request to substitute the claim of a deceased claimant.

SECTION I - IDENTIFYING INFORMATION

NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite
processing of the form.
1. FIRST, MIDDLE INITIAL, LAST NAME OF DECEASED CLAIMANT (Print clearly if completing by hand)
2. VETERAN'S FILE NUMBER

3. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Month

Day

5. DECEASED CLAIMANT'S DATE OF DEATH (MM/DD/YYYY)

Year

Month

Day

Year

SECTION II - SUBSTITUTE CLAIMANT INFORMATION

I have interest in the claim of the deceased and request to be substituted as the claimant. I am eligible to receive accrued benefits due the deceased
claimant and I am eligible to be a substitute claimant under section 5121(a) of title 38.
6. FIRST, MIDDLE INITIAL, LAST NAME OF SUBSTITUTE CLAIMANT (Print clearly if completing by hand)

7. RELATIONSHIP TO DECEASED

8. CLAIMANT'S SOCIAL SECURITY NUMBER

9. ADDRESS OF CLAIMANT (No. and Street or rural route, City or P.O., State and ZIP Code)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

10. CLAIMANT'S TELEPHONE NUMBER(S)
A. DAYTIME PHONE NUMBER

B. EVENING PHONE NUMBER

C. CELL PHONE NUMBER

11. E-MAIL ADDRESS (Optional) (NOTE: By providing your E-mail address you provide consent for VA to contact you via

E-mail and that those E-mails may contain personal identifiable information. However, VA will never include your
SSN in E-mail correspondence.)

12. FAX NUMBER (If applicable)

13. REMARKS

14A. SIGNATURE (Do NOT print)

14B. DATE SIGNED (MM/DD/YYYY)

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. 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. You are required
to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may disclose
them for purposes stated above.
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 2900-0740, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 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
Offic er at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0740 in any correspondence. Do not send your completed VA Form 21P-0847 to this email address.
VA FORM
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21P-0847

SUPERSEDES VA FORM 21P-0847, DEC 2021

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