Statement of Marital Relationship (VA Form 21-4170)

OMB 2900-0114

OMB 2900-0114

VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established. VA Form 21-4170 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

The latest form for Statement of Marital Relationship (VA Form 21-4170) expires 2020-11-30 and can be found here.

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