Form 21-524 Statement of Person Claiming to Have Stood in Relation o

NOT FOR REPRODUCTION

OMB Control No. 2900-0059
Respondent Burden: 2 Hours

STATEMENT OF PERSON CLAIMING TO HAVE STOOD IN RELATION OF PARENT
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what have 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, Compensation, Pension, Education, and
Rehabilitation Records - VA, and 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 U.S.C. 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 a 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: We need this information to determine eligibility for service-connected death benefits (38 U.S.C. 1315 and 5101). Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 2 hours to review the instructions, find the information, and complete this form. VA
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this
number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If
desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
INSTRUCTIONS: Answer all questions as fully as possible. If you do not know the answer, enter "Unknown." If additional space is needed, attach a SIGNED sheet of
paper indicating the item number to which the answer apply. Parts II and III should each be completed by disinterested persons who have personal knowledge of the
relationship which existed between the claimant and the veteran.
2. VA FILE NUMBER
1. FIRST NAME - MIDDLE NAME - LAST NAME OF DECEASED VETERAN (Typed or print)
XC-/XSS
PART I - STATEMENT OF CLAIMANT
3B. DAYTIME TELEPHONE NUMBER (Include Area Code)

3A. NAME AND ADDRESS OF CLAIMANT (Including ZIP Code)

3C. EVENING TELEPHONE NUMBER (Include Area Code)

5A. CLAIMANT'S SOCIAL SECURITY NUMBER

4. YOUR RELATIONSHIP TO VETERAN BY BLOOD OR
MARRIAGE (Stepfather, Sister, etc., if none state "None")

6A. ARE YOU MARRIED TO A PARENT OF THE VETERAN?
YES

NO

6B. DATE OF MARRIAGE

5B. CLAIMANT'S DATE OF BIRTH

6C. PLACE OF MARRIAGE

(If "Yes", complete 6B and 6C)
INFORMATION ABOUT THE VETERAN

7A. VETERAN'S DATE OF BIRTH

7B. VETERAN'S SOCIAL SECURITY NUMBER

8. PLACE OF BIRTH

9. DATE OF DEATH

10. PLACE OF DEATH

11A. NAME OF VETERAN'S OWN FATHER (If deceased, complete 11B)

12A. NAME OF VETERAN'S OWN MOTHER (If deceased, complete 12B)

11B. DATE OF DEATH OF VETERAN'S OWN FATHER

12B. DATE OF DEATH OF VETERAN'S OWN MOTHER

11C. ADDRESS OF VETERAN'S OWN FATHER, IF LIVING

12C. ADDRESS OF VETERAN'S OWN MOTHER, IF LIVING

13A. WAS VETERAN EVER MARRIED?

13B. FULL NAME OF SPOUSE

YES

NO

(If "Yes", complete 13B and 13D)
13D. ADDRESS OF SPOUSE, IF LIVING

13C. DATE OF MARRIAGE

INFORMATION ABOUT SURVIVING BROTHERS AND SISTERS OF VETERAN
14A. NAME

VA FORM
NOV 2004

21-524

14B. AGE

EXISTING STOCKS OF VA FORM 21-524, MAR 1997,
WILL BE USED.

14C. ADDRESS

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NOT FOR REPRODUCTION
INFORMATION ABOUT THE VETERAN
15A. DATE VETERAN WAS PLACED IN
YOUR CUSTODY OR CARE

15B. NAME AND ADDRESS OF ORGANIZATION, INSTITUTION, OR PERSON THAT PLACED THE
VETERAN IN YOUR CUSTODY OR CARE

IMPORTANT - If you entered into a written agreement at the time veteran was placed in your custody or care, attach a copy of the agreement.
16. CIRCUMSTANCES OF YOUR OBTAINING CUSTODY OR CARE OF THE VETERAN (Explain fully)

17. NAME OF HEAD OF HOUSEHOLD IN WHICH YOU LIVED AT TIME YOU ASSUMED ALLEGED RELATIONSHIP OF PARENT TO VETERAN

18A. NAME AND ADDRESS OF PERSON WHO
PROVIDED VETERAN WITH A PLACE TO LIVE
AFTER YOU ASSUMED ALLEGED RELATIONSHIP
OF PARENT TO VETERAN

18B. PERIOD(S) OF TIME THIS
PERSON FURNISHED VETERAN
WITH A PLACE TO LIVE
FROM

18C. ADDRESSES AT WHICH VETERAN LIVED
DURING PERIOD SHOWN IN ITEM 18B

TO

19A. DID YOU PROVIDE FOR SCHOOLING OR TRAINING OF VETERAN?
YES

NO

(If "Yes", complete Items 19B, 19C and 19D)

19B. DATE
FROM

TO

19C. NAME AND ADDRESS OF SCHOOL

19D. TYPE OF COURSE OR
TRAINING TAKEN

20. APPROXIMATE AMOUNTS SPENT BY YOU FOR VETERAN'S SUPPORT, CLOTHING, SCHOOLING, AND OTHER NECESSARY EXPENSES (Explain fully)

ORGANIZATIONS, INSTITUTIONS, AND PERSONS THAT CONTRIBUTED TO VETERAN'S SUPPORT (If none, state "None")
21A. NAME AND ADDRESS

21B. AMOUNT OF CONTRIBUTION

21C. PURPOSE

21D. DATE OF CONTRIBUTION

ORGANIZATIONS, INSTITUTIONS, AND PERSONS THAT CONTRIBUTED TO VETERAN'S SUPPORT (If none, state "NONE")
22A. NAME

22B. ADDRESS

(If person is deceased, give date of death.)

22C. DATES OF CUSTODY OR CARE

(If exact dates are unknown give
approximate dates)

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NOT FOR REPRODUCTION
INFORMATION ABOUT THE RELATIONSHIP (Continued)
23A. DID VETERAN CONTRIBUTE TO YOUR SUPPORT AT ANY TIME?
(If "Yes", complete Item 23B)
YES
NO
23B. AMOUNT CONTRIBUTED AND CIRCUMSTANCES UNDER WHICH CONTRIBUTED (Explain fully)

INFORMATION ABOUT VETERAN'S EMPLOYMENT
24A. WAS VETERAN EMPLOYED DURING PERIOD HE/SHE WAS IN YOUR CUSTODY OR CARE?
YES

NO

(If "Yes", complete Items 24B, 24C and 24D)

24B. DATE OF EMPLOYMENT

24C. NAME AND ADDRESS OF EMPLOYER

24D. AMOUNT EARNED

25. DID THE VETERAN IN A NOTE, LETTER, DOCUMENT, INSURANCE POLICY OR ANY RECORD, REFER TO YOU AS A PARENT?
YES

NO

(If "Yes", explain fully)

IMPORTANT - Attach letters, notes, records or other evidence which tend to show the relationship which existed between you and the veteran.
This evidence will be returned to you, if requested.
26. OTHER FACTS WHICH SHOW THE RELATIONSHIP THAT EXISTED BETWEEN YOU AND THE VETERAN

CERTIFICATE AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
27. DATE

28. SIGNATURE OF CLAIMANT

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

NOTE: Signatures made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the
signature and addresses of the witnesses must be shown below.
29. SIGNATURE OF WITNESS

30. ADDRESS OF WITNESS

31. SIGNATURE OF WITNESS

32. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or evidence of a
material fact, knowing it to be false.
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NOT FOR REPRODUCTION
PART II - STATEMENT OF DISINTERESTED PERSON NO. 1

NOTE: Read Instructions on page1 before completing.
1. NAME AND ADDRESS OF DISINTERESTED PERSON

2. AGE

3. OCCUPATION

4. YOUR RELATIONSHIP TO DECEASED VETERAN

5. LENGTH OF TIME YOU KNEW VETERAN

6. YOUR RELATIONSHIP TO CLAIMANT

7. LENGTH OF TIME YOU HAVE KNOWN CLAIMANT

8. WERE YOU IN A POSITION PERSONALLY TO OBSERVE THE CONDUCT AND ATTITUDE OF THE CLAIMANT AND THE VETERAN TOWARD EACH OTHER?
YES

NO

(If "Yes", explain fully your position to make these observations and give number of months or years you observed this relationship)

9. FACTS BASED ON YOUR PERSONAL KNOWLEDGE WHICH SHOW WHETHER OR NOT CLAIMANT ACTED AS "PARENT" TO THE VETERAN (Explain in detail,

giving facts relating to veteran's support, guidance, training. etc.)

INFORMATION ABOUT PERIODS OF TIME VETERAN LIVED IN SAME HOUSEHOLD WITH CLAIMANT
10A. DO YOU KNOW OF YOUR OWN KNOWLEDGE WHETHER THE VETERAN LIVED IN THE SAME HOUSEHOLD WITH THE CLAIMANT?
(If "Yes", complete Items 10B and 10C)
YES
NO
10B. DATES
FROM

TO

10C. ADDRESS

11. DO YOU KNOW OF YOUR PERSONAL KNOWLEDGE WHO SUPPORTED THE VETERAN?
YES

NO

(If "Yes", explain in detail)

12. DID ANY OTHER PERSONS STAND IN THE RELATIONSHIP OF PARENT TO THE VETERAN?
YES

NO

(If "Yes", explain fully)

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NOT FOR REPRODUCTION
PART II - STATEMENT OF DISINTERESTED PERSON NO. 1 (Continued)
13. WHAT IS THE MEANS OF YOUR KNOWLEDGE OF THE INFORMATION FURNISHED IN ITEMS 9 THROUGH 12?

14. PLACES WHERE YOU LIVED, AND DATES OF EACH RESIDENCE, DURING PERIOD CLAIMANT ALLEGED CUSTODY OR CARE OF VETERAN

CERTIFICATE AND SIGNATURE OF DISINTERESTED PERSON

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15. DATE

16. SIGNATURE OF DISINTERESTED PERSON

WITNESSES TO SIGNATURE OF DISINTERESTED PERSON IF MADE BY "X" MARK

NOTE: Signatures made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the
signature and addresses of the witnesses must be shown below.
17. SIGNATURE OF WITNESS

18. ADDRESS OF WITNESS

19. SIGNATURE OF WITNESS

20. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or
evidence of a material fact, knowing it to be false.
PART III - STATEMENT OF DISINTERESTED PERSON NO. 2

NOTE: Read Instructions on page 1 before completing.
1. NAME AND ADDRESS OF DISINTERESTED PERSON (Type or Print)

2. AGE

3. OCCUPATION

4. YOUR RELATIONSHIP TO DECEASED VETERAN

5. LENGTH OF TIME YOU KNEW VETERAN

6. YOUR RELATIONSHIP TO CLAIMANT

7. LENGTH OF TIME YOU HAVE KNOWN CLAIMANT

8. WERE YOU IN A POSITION PERSONALLY TO OBSERVE THE CONDUCT AND ATTITUDE OF THE CLAIMANT AND THE VETERAN TOWARD EACH OTHER?
YES

NO

(If "Yes", explain fully your position to make these observations and give number of months or years you observed this relationship)

9. FACTS BASED ON YOUR PERSONAL KNOWLEDGE WHICH SHOW WHETHER OR NOT CLAIMANT ACTED AS "PARENT" TO THE VETERAN ( Explain in detail,

giving facts relating to veteran's support, guidance, training, etc.)

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NOT FOR REPRODUCTION
PART III - STATEMENT OF DISINTERESTED PERSON NO. 2 (Continued)
INFORMATION ABOUT PERIODS OF TIME VETERAN LIVED IN THE SAME HOUSEHOLD WITH CLAIMANT
10A. DO YOU KNOW OF YOUR OWN KNOWLEDGE WHETHER THE VETERAN LIVED IN THE SAME HOUSEHOLD WITH THE CLAIMANT?
(If "Yes", complete Items 10B and 10C)
YES
NO
10B. DATES
FROM

10C. ADDRESS

TO

11. DO YOU KNOW OF YOUR PERSONAL KNOWLEDGE WHO SUPPORTED THE VETERAN?
YES

NO

(If "Yes", explain in detail)

12. DID ANY OTHER PERSONS STAND IN THE RELATIONSHIP OF PARENT TO THE VETERAN?
YES

NO

(If "Yes", explain fully)

13. WHAT IS THE MEANS OF YOUR KNOWLEDGE OF THE INFORMATION FURNISHED IN ITEMS 9 THROUGH 12?

14. PLACES WHERE YOU LIVED, AND DATES OF EACH RESIDENCE, DURING PERIOD CLAIMANT ALLEGED CUSTODY OR CARE OF VETERAN

CERTIFICATE AND SIGNATURE OF DISINTERESTED PERSON

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15. DATE

16. SIGNATURE OF DISINTERESTED PERSON

WITNESSES TO SIGNATURE OF DISINTERESTED PERSON IF MADE BY "X" MARK

NOTE: Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the
signatures and addresses of the witnesses must be shown below.
17. SIGNATURE OF WITNESS

18. ADDRESS OF WITNESS

19. SIGNATURE OF WITNESS

20. ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for willful submission of any statement or evidence of a
material fact, knowing it to be false.
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