Form 21-0788 Information Regarding Apportionment of Beneficiary's Awa

OMB Approved No. 2900-0666
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

INFORMATION REGARDING APPORTIONMENT OF
BENEFICIARY'S AWARD

(DO NOT WRITE IN THIS SPACE)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to
apply for an apportionment. For more information, you can contact us online through Ask VA: https://ask.va.gov/. Ask us
a question online or call us toll-free at 1-800-827-1000 (TTY:711). VA forms are available at www.va.gov/vaforms.
IMPORTANT: In certain limited circumstances a veteran's disability award may be apportioned (paid) to the veteran's spouse, child, or dependent parent. A
surviving spouse's award may also be apportioned for the veteran's child or children. This form must be completed by the spouse, child, or dependent parent
requesting the apportionment, or by an individual acting on behalf of a minor child. 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 became eligible for benefits) (38 U.S.C. § 103(c)).

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 check box to help expedite processing of the form.

1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER

SECTION II: INFORMATION ON CLAIMANT OR INDIVIDUAL ACTING ON BEHALF OF A MINOR CHILD
5. YOUR NAME (First, Middle Initial, Last)

6. RELATIONSHIP TO VETERAN
CURRENT SPOUSE

CHILD 18-23 IN SCHOOL

CUSTODIAN FILING FOR CHILD UNDER 18

DEPENDENT PARENT

CHILD OVER 18 PERMANENTLY INCAPABLE OR SELF-SUPPORT
OTHER (Specify)
7. YOUR ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

8. TELEPHONE NUMBER (Include Area Code)

9. E-MAIL ADDRESS (Optional)

SECTION III: APPORTIONMENT INFORMATION
(Only complete the portion of this section that applies to you)
10. PERSON(S) YOU ARE REQUESTING AN APPORTIONMENT FOR:
A. NAME OF INDIVIDUAL FOR WHOM
APPORTIONMENT IS REQUESTED
(First, Middle Initial, Last)

B. SOCIAL SECURITY
NUMBER

C. RELATIONSHIP TO THE
VETERAN

D. IS THE INDIVIDUAL
CURRENTLY IN RECEIPT
OF AN APPORTIONMENT
YES

NO

YES

NO

YES

NO

YES

NO

11. IF ANY PERSON LISTED IN 10A IS THE VETERAN'S STEPCHILD, IS THE STEPCHILD STILL LIVING IN THE VETERAN'S HOUSEHOLD?
YES
NO (If “NO,” provide the date the stepchild(ren) left the veteran's household) (MM/DD/YYYY):
VA FORM
XXX 20XX

21-0788

SUPERSEDES VA FORM 21-0788, AUG 2024.

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12. HAS THE VETERAN'S CHILD(REN) FOR WHOM THE APPORTIONMENT IS CLAIMED BEEN LEGALLY ADOPTED BY ANOTHER PERSON?
YES

NO

13A. PROVIDE THE REASON FOR THE APPORTIONMENT CLAIM
Veteran is incarcerated for more than 60 days as a result of conviction for a

felony or

Surviving spouse or child is incarcerated for more than 60 days as a result of a conviction for a

misdemeanor (38 U.S.C 5313).
felony or

misdemeanor (38 U.S.C 5313).

Veteran is incompetent, without fiduciary, and is receiving hospital treatment, nursing home, or domiciliary care provided by the United States or
political subdivision and the veteran's benefits are not being paid to the veteran's spouse (38 U.S.C 5307 and 5502).
Veteran is in receipt of pension and is receiving hospital, domiciliary or nursing home care by the United States or a political subdivision. (38 U.S.C.
5503)
The primary beneficiary resides in the territory of or under the control of an enemy of the United States or its allies. (38 U.S.C 5308).
The veteran has disappeared for 90 days or more and his/her whereabouts remain unknown. (38 U.S.C. 1158)
13B. PROVIDE THE NAME AND ADDRESS OF THE FACILITY WHERE THE BENEFICIARY IS
INCARCERATED OR RECEIVING CARE (If applicable)
NAME OF FACILITY

ADDRESS OF FACILITY

SECTION IV: REMARKS
14. REMARKS (If any)

SECTION V: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
15A. SIGNATURE OF CLAIMANT OR INDIVIDUAL ACTING ON BEHALF OF A MINOR CHILD (Required)

15B. DATE SIGNED (MM/DD/YYYY)

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 https://www.va.gov/
disability/upload-supporting-evidence/. You can also go directly to AccessVA 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 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

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

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 is false, or
fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION : The 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 State 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, 58VA 21/22/28, 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.

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 2900-0666, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 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 vapra@va.gov.
Please refer to OMB Control No. 2900-0666 in any correspondence. Do not send your completed VA Form 21-0788 to this email address.

VA FORM 21-0788, AUG 2024

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