Form VA Form 21-601 VA Form 21-601 Application for Accrued Amounts Due a Deceased Beneficia

INSTRUCTIONS FOR VA FORM 21-601
APPLICATION FOR ACCRUED AMOUNTS DUE A DECEASED BENEFICIARY
Note: Do not complete this form if you have applied for death benefits by using VA Form 21-534 or 21-535.
Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
If you have questions about this form, how to fill it out, or about benefits, contact your nearest VA regional office. You
can locate the address of the nearest regional office in your telephone book blue pages under "United States Government,
Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833). You may also contact VA by Internet at
http://iris.va.gov.
B. What do I use VA Form 21-601 for?
Use VA Form 21-601 to apply for accrued benefits due the beneficiary but not paid prior to death. Each person
claiming a share of accrued benefits must complete a separate VA Form 21-601.
Note: If you are a deceased veteran's surviving spouse, child, or dependent parent, you should apply for death benefits,
including accrued benefits, using VA Form 21-534, Application for Dependency and Indemnity Compensation, Death
Pension and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) or VA
Form 21-535, Application for Dependency and Indemnity Compensation by Parent(s) (Including Accrued Benefits and
Death Compensation, When Applicable).
C. What are accrued benefits and how does VA decide what I will or will not receive?
Accrued benefits are benefits that were due the beneficiary at the time of death but not paid prior to death. Entitlement to
accrued benefits is determined according to the line of succession established by law.
Benefits are payable to the first living person listed below. The fact that a preferred beneficiary fails to file or prosecute a
claim does not permit payment of his/her share of accrued benefits to a person or persons having an equal or lower
preference. A waiver of right also does not permit such payment. If there are no living persons who are entitled on the
basis of relationship, accrued benefits may be payable as reimbursement for last illness and burial expenses
(see Paragraph D).
When the deceased beneficiary is a
veteran, accrued is payable
in full to the surviving spouse, or
in equal shares to the veteran's children
(see definition of "child" below), or
in equal shares to the veteran's parents,
if they are dependent upon the veteran
at the date of the veteran's death, or
in full to the sole surviving parent, if
he/she is dependent upon the veteran at
the date of the veteran's death.

When the deceased beneficiary is a
surviving spouse, accrued is payable

When the deceased beneficiary
is a child, accrued is payable

in equal shares to the veteran's
children (see definition of
"child" below).

in equal shares to the veteran's
children who are entitled to
death compensation,
dependency and indemnity
compensation, or death pension
(see definition of "child"
below).

Definitions:
Child means an unmarried child of the veteran who is under 18 years of age, or at least 18 but under 23 years of age and
pursuing an approved course of education, or became incapable of self support prior to reaching age 18. However,
benefits may be payable to the veteran's children, regardless of age or marital status, if lump sum accrued benefits are
payable.
Lump sum accrued benefits are amounts withheld from a competent veteran's Old Law Pension benefits (fixed rate
since 1960) during hospital treatment, or institutional or domiciliary care.
VA FORM
MAY 2005

21-601

SUPERSEDES VA FORM 21-551, JAN 2002, 21-601, FEB 2002,
21-609, OCT 2002 AND 21-614, FEB 1995, WHICH WILL NOT BE USED.

D. Who may file a claim for reimbursement for last illness and burial expenses?
If there are no living persons who are entitled on the basis of relationship, accrued benefits may be used to reimburse the
person or persons who paid for or are responsible to pay the expenses of last illness and burial of a beneficiary. The claim
should be filed by the person or persons whose funds were or will be used to pay such expenses. If the expenses were
paid from funds of the deceased beneficiary's estate, the claim should be filed by the executor or administrator of the
estate. If the expenses have not been paid, the claim may be filed by the person who is responsible for the payment of
these expenses. However, all unpaid creditors must sign Part IV, Reimbursement Waiver.
E. What are the time limits to apply for accrued benefits?
A claim for accrued benefits must be filed within one year from the date of death of the deceased beneficiary.
Exception: A claim for lump sum accrued benefits (benefits that were withheld from a competent veteran during hospital
treatment, institutional, or domiciliary care) must be filed within five years from the veteran's date of death. However, if
the person who is entitled to the lump sum accrued benefits has been declared incompetent by a court of law or Federal or
State government agency at the time of the veteran's death, the five year period begins from the date of termination or
removal of the finding of incompetency.
F. What evidence should I submit?
1. Furnish a copy of the death certificate unless the beneficiary died in a VA medical facility.
2. If an executor or administrator of the beneficiary's estate has been assigned, submit a certified copy of the letters of
administration or letters testamentary bearing the signature and seal of the appointing court.
3. If you are claiming reimbursement for last illness and burial expenses of a beneficiary, submit all bills and statements
of account covering the services and supplies that were provided in connection with these expenses. The bill or statement
of account should be submitted on the regular billhead of the creditor and show:
the dates, nature, and costs of services or supplies provided,
the name of the deceased for whom the expenses were incurred, and
whether the expense has been paid, and, if so, by whom.
G. How do I complete my application?
Print all answers clearly. If an answer is "none" or "0," write that. Your answer to every question is important to help us
complete your claim. If you do not know the answer, write "unknown." For additional space, use Item 23, "Remarks, " or
attach a separate sheet, indicating the item number to which the answers apply. Write the veteran's name and VA file
number on all attachments. Make sure you sign and date this application (Items 20a and 20b).
H. What do I do when I have completed my application?
When you have completed this application mail it or take it to a VA regional office. Be sure to attach any materials that
support and explain your claim. Also, make a photocopy of your application and everything that you submit to VA before
you mail it.
Privacy Act Notice: 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 5, Code of Federal Regulations 1.526 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. 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: We need this information to determine eligibility for payment of accrued benefits under 38 U.S.C.
5121. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of
30 minutes 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/library/omb/OMBINVC.html#VA. If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.

OMB Approved No. 2900-0216
Respondent Burden: 30 minutes
VA DATE STAMP
(Do not write in this space)

Application for Accrued Amounts Due a Deceased Beneficiary
Please read the attached "Instructions" before you fill out this form.

SECTION I
Tell us about you
and the deceased
beneficiary

1. What is the veteran's name?
First

Middle

Last

2. What is the veteran's Social Security Number?

3. What is the VA file number?

4. What is the name of the deceased beneficiary? (If other than veteran)
First
Middle
5. What is the date of death of the beneficiary?
mo day

Last

yr

6. What is your name?
First
7. What is your address?

Middle

Last

Street address, Rural Route, or P.O. Box

Apt. number
State

City

Country

ZIP Code

8. What are your telephone numbers? (Include Area Code)
Daytime
Evening
9. What is your relationship to the deceased beneficiary?

SECTION II
Tell us about the
deceased
beneficiary's
surviving relatives

10. Who are the deceased beneficiary's surviving relatives? (Check all that apply)
Spouse

Child or Children

Mother

Father

None

(If "NONE," Skip to Section II)

If any boxes are checked in Item 10, list each person separately in Item 11a through 11d.

11. Relatives Surviving Beneficiary at time of death
11a. Name
(First, Middle Initial, Last)

VA FORM
MAY 2005

21-601

11b. Relationship to
Beneficiary

11c. Date of Birth 11d. Complete Mailing Address
(mm/dd/yyyy)

SUPERSEDES VA FORM 21-551, JAN 2002, 21-601, FEB 2002,
21-609, OCT 2002 AND 21-614, FEB 1995, WHICH WILL NOT BE USED.

21-601

page 1

SECTION III

Note: Read Paragraphs C and D of the "Instructions" before completing Section III. Skip to Section V
if you are claiming accrued benefits based on your relationship to the deceased beneficiary.

Tell us about the
debts and expenses
of the last sickness
and burial of the
deceased
beneficiary

12. List the expenses of last sickness and burial in Items 12a through 12e.
12b. Nature of Expense 12c. Amount
(For example, physician,
hospital, burial expenses,
etc.)

12a. Name of Person or Firm

12d. Check One 12e. If Paid, Name of Person
or Estate Whose Funds Were
Used
Paid Unpaid

$

$

$

$

13. Have you been reimbursed from any source
for any of the expenses paid from your
personal funds?
Yes

No (If "YES," specify the amount

14. Did the beneficiary leave any other debts?

Yes

and source)

No (If "YES," go to Item 15.
If "NO," skip to Item 16.)

15. List the other debts in Items 15a and 15b.
15a. Nature of Debt

15b. Amount
$
$
$
$

16. Has or will the beneficiary's estate be legally administered?
Yes

No

(If "YES," attach a copy of the letters of administration or letters
testamentary bearing the signature and seal of the appointing
court)

21-601

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SECTION IV
Give us a waiver of
reimbursement
from all unpaid
creditors

Note: If any of the expenses listed in Item 12a are unpaid, Section IV must be completed and signed by all
unpaid creditors. If you are a creditor who is claiming accrued benefits as reimbursement, Section IV must
be completed by all other creditors and persons who provided services to the deceased beneficiary related to
last illness or burial and hold the creditor responsible for payment of their claims. If you need additional
space, please attach a separate sheet of paper providing the certification and information requested below.
I CERTIFY THAT the expense listed in Section III, Item 12a which was incurred by the claimant named in
Item 6 in connection with the last sickness and burial of the beneficiary, is due and unpaid. I further certify
that I hold the claimant responsible for the payment of any portion of the accrued benefit to which I may be
entitled in the case of the beneficiary named in Item 1 or 4 and waive my right to any such benefit. This
statement is true and correct to the best of my belief.
17a. Name of Unpaid Creditor or Firm No. 1
17b. Address of Creditor or Firm

17c. Signature of Creditor or Person
Signing for Firm

17d. Title

17e. Date Signed

mo day

yr

18a. Name of Unpaid Creditor or Firm No. 2
18b. Address of Creditor or Firm

18c. Signature of Creditor or Person
Signing for Firm

18d. Title

18e. Date Signed

mo day

yr

19a. Name of Unpaid Creditor or Firm No. 3
19b. Address of Creditor or Firm

19c. Signature of Creditor or Person
Signing for Firm

19d. Title

19e. Date Signed

mo day

yr

SECTION V

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

Give us your
Signature

20a. Signature of claimant

If you sign with an "X,"
then you must have two
people you know witness
you as you sign. They
must then sign the form
and print their names and
addresses also.

20b. Today's date
mo day yr

21a. Signature of witness (If claimant
signed above using an "X")

21b. Printed name and address of witness

22a. Signature of witness (If claimant
signed above using an "X")

22b. Printed name and address of witness

21-601

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SECTION VI

23. Remarks (If you need more space to answer a question or have a comment about a specific item
number on this form, please identify your answer or statement by the Section and item number)

Remarks - Use this
space for any
additional
statements
that you would like
to make concerning
your application.

IMPORTANT
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, or for the
fraudulent acceptance of
any payment which you
are not entitled to.

21-601

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