Form VA Form 21-534 VA Form 21-534 Application for Dependency and Indemnity Compensation, D

GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION AND ACCRUED BENEFITS BY A SURVIVING SPOUSE
OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21-534

NOTE: Read very carefully, detach, and keep these instructions for your reference
A. How can I contact VA if I have questions?

2. Death pension may be payable when:

If you have any questions about this form, how to fill it out, or
about VA 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 1-800-829-4833). You may
also contact VA by Internet at http://iris.va.gov.

the death of a veteran with wartime service is
not due to service, and
income is within applicable limits.
VA pays pension based on the amount of family income and
the number of dependent children. This is based on law. VA
must include as income all sources that Federal law specifies.
If there is no surviving spouse, pension may be payable on
behalf of a child or children.

.
.

B. What is the purpose of VA Form 21-534?
Use VA Form 21-534 to apply for:

.
.

VA benefits you may be entitled to receive as a
surviving spouse or child of a deceased veteran, and
any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).

If you apply for any one of these benefits, the law requires
that we also consider you for the others.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security (SS) benefits by using the
SSA-24 form attached to this VA Form (see pages 9 and 10).
You don’t have to apply if you don’t want to or have already
done so. If you do want to apply, fill it out and leave it
attached. We will send it to the Social Security
Administration for you. They will then contact you.
D. What are dependency and indemnity compensation
(DIC) and death pension benefits, and how does VA
decide what I will or will not receive?
1. Dependency and indemnity compensation may be payable
when:

..
.

a veteran’s death occurred in service, or
a veteran dies of a service-connected disability, or
in certain circumstances if a veteran rated totally
disabled from service-connected disability dies
from non-service-connected conditions.

Unless a claim for dependency and indemnity compensation
or death pension is filed within one year from the date of the
veteran’s death, that benefit is not payable from a date earlier
than the date the claim is received in VA.
If it is determined that you are entitled to DIC and death
pension, we will pay you whichever benefit entitles you to the
most money. Benefit rates and income limits are frequently
changed, so it is not possible to keep this information current
in these instructions. You can find out what the current
income limitations and rates of benefits are by contacting
your nearest VA regional office.
E. How do I apply for aid and attendance allowance
and/or housebound benefits?
VA may pay a higher rate of DIC or pension to a surviving
spouse who is blind, a patient in a nursing home, other wise
needs regular aid and attendance, or who is permanently
confined to his or her home because of a disability. If you
wish to apply for this benefit, check "Yes" for Item 31.
F. 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 48, "Remarks," or
attach a separate sheet, indicating the item number to which
the answers apply. Make sure you sign and date this
application (Items 44 and 45).
NOTE: If the claim is being made on behalf of a minor or
incompetent person, the application form should be
completed and filed by the legal guardian. If no legal
guardian has been appointed, it may be completed and filed
by some person acting on behalf of the minor or
incompetent person.

VA FORM
JUN 2005

21-534

SUPERSEDES VA FORM 21-534, JUN 1998,
WHICH WILL NOT BE USED.

General Instructions

PAGE 1

G. 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
mailing it.

VA Form 21-22, Appointment of Veterans Service
Organization as Claimant’s Representative, or VA Form 22A,
Appointment of Individual as Claimant’s Representative. You
may
also
download
these
forms
at
http://www.va.gov/vaforms/ . If you have already designated a
representative, no further action is required on your part.
I. What if I believe that VA has made an error in
processing or deciding my benefits?

H. How can I assign someone to act as my representative?
A representative can be an accredited member of an
accredited organization or other service organization that the
Secretary of Veterans Affairs recognizes, an agent recognized
by VA, or a licensed lawyer. Agents and attorneys can charge
you for services that you get from them only after the Board
of Veterans’ Appeals (BVA) gives you their final decision
about your application. That means you can use an attorney
during any stage of your application for benefits. However,
the agent or attorney cannot charge you for services unless
you are trying to resolve a dispute with VA after BVA has
made a decision about your claim.

You can ask for a personal hearing at any time during the
processing of your claim. That means you can ask for the
hearing while VA is processing your claim or after VA has
made a decision. You should contact the nearest VA office
and tell them that you want a personal hearing on your case.
Someone in the local VA office will arrange a time and place
for your hearing. At this hearing, you can bring witnesses. VA
will record whatever you and your witnesses say during the
hearing and include it in the official record. VA will furnish
the hearing room and officials, and prepare a transcript of the
hearing. VA cannot pay your expenses or the expenses of
anyone you want to bring with you to the hearing.

If you want to use a representative to help you with your
application, contact the nearest VA office. Depending on the
type of representative you want to designate, we will send you
one of the following forms:

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 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 USC 5101 (c)(1). The VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January
1, 1975, and still in effect. 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 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 death benefits and accrued benefits under 38
U.S.C. 1310 through 1314, 1532 through 1543, and 5121. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 1hour and 15 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/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.

General Instructions

PAGE 2

OMB Approved NO 2900 0004
Respondent Burden: I hour 15 minutes

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

Application for Dependency and Indemnity Compensation, Death Pension and Accrued
Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable)
VA Form 21-534

Please read the attached "General Instructions" before you fill out this form.
1. Did the veteran ever file a claim with VA?

SECTION
I

YES
YES

Tell us what you
are applying for
and what you and
the deceased
veteran have
applied for

NO

2. What is the VA file number?

(If "Yes," answer Item 2)

NO

3. Has the surviving spouse or child ever filed a
claim with VA?
YES

NO

4. What is the VA file number?

(If "Yes," answer Items 4
through 6)

5. What is the name of the person on whose service the claim was filed?
First

Middle

Last

6. What is your relationship to that person?

7. Are you claiming service connection for cause of death?
YES

NO

8. What is the veteran’s name?

SECTION
II

First

Middle

Last

9. What is the veteran’s Social Security number?

Tell us
about you
and the
deceased
veteran

Suffix (If applicable)

10a. Did the veteran serve under another name?
YES

NO

(If "Yes," answer Item 10b)

10b. Please list the other name(s) the veteran
served under:

11. What is the veteran’s date of birth?

mo day yr

Attach a copy of the
death certificate
unless the veteran
died in active service
of the Army, Navy,
Air Force, Marine Corps,
or Coast Guard, or in a
U.S. government
institution.

12. What is the veteran’s date of death?

13. Was the veteran a former prisoner of war?
YES

mo day yr
14. What is your name? (First, Middle, Last Name)

NO

15. What is your relationship to the veteran?
(check one)
Surviving Spouse

Child

16. What is your address?

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

City

State

Apt. number

ZIP Code

Country

17. What are your telephone numbers?
(Include Area Code)

18. What is your e-mail address?
(Include Area Code)

19. What is your Social Security number?

20. What is your date of birth?

mo day yr
VA FORM
JUN 2005

21-534

SUPERSEDES VA FORM 21-534, JUN 1998,
WHICH WILL NOT BE USED.

21-534

PAGE 1

SECTION Tell us
III
about the
veteran’s
active duty
service

21a. Did the veteran ever
file a claim with VA?

1. Enter complete information for

21d. Left this Active
Service

Note: Skip to Section IV if the veteran was receiving VA compensation or pension at the
time of his/her death.

mo day

21b. Place

21c. Service Number

21e. Place

21f. Branch of Service

21i. Place

21j. Service Number

21l. Place

21m. Branch of Service

yr
21g. Grade, Rank,
or Rating

all periods of service. If more
mo day

space is needed use Item 48
"Remarks."

yr

21h. Entered Active
Service (second period)
2. If the veteran never files a
claim with VA, attach the

mo day

yr

original DD214 or a certified
copy for each period of service
listed. We will return original

21k. Left This Active
Service
mo day

documents to you.

SECTION Tell us
IV
about your
and the
veteran’s
marital
history
Attach a copy of your
marriage certificate showing your
marriage to the veteran.

21n. Grade, Rank,
or Rating

yr

NOTE: Skip to Section V if the veteran was receiving additional VA benefits for you
as his/her spouse at the time of his/her death unless you remarried after the veteran’s
death.

You must furnish complete information about all marriages of the surviving
spouse and the veteran. If you need additional space, please attach a separate
sheet of paper providing the requested information about the marriages.

The veteran’s marriages
22a. How many times was the veteran married?
22b. Date of
Marriage

22c. Place
(city, state or country)

(mo

day yr)

(mo

day yr)

22d. To whom
married

22e. Date
marriage ended

(first, middle initial,
last name)

22f. Place

22g. How marriage
ended

(city, state or country)

(mo

day yr)

(mo

day yr)

(death, divorce)

The surviving spouse’s marriages. Note: Items 23a through 27 should be completed by the veteran’s surviving spouse. If the claimant is not
the surviving spouse, skip to Section V.
23a. How many times were you married?
23c. Date of
Marriage

23d. Place
(city, state or country)

23b. Have you remarried since the death of the veteran?
23e. To whom
married

23f. Date
marriage ended

(first, middle initial,
last name)

Yes

23g. Place

23h. How marriage
ended

(city, state or country)

(mo

day yr)

(mo

day yr)

(mo

day yr)

(mo

day yr)

No

21-534

(death, divorce)

PAGE 2

SECTION IV Tell us about your and the veteran’s marital history (continued)
Answer Item 24 only if you
were married to the
veteran for less than one year.

24. Was a child born to you and the veteran during
your marriage or prior to your marriage?
YES

25. Are you expecting the birth of a child of the
veteran?
YES

NO

26. Did you live continuously with the veteran from
the date of marriage to the date of his/her death?

YES

NO

27. What was the cause of the separation? Give the
reason, date(s), and duration of the separation.
If the separation was by court order, attach a
copy of the order.

NO

(If "No," answer Item 27)

SECTION Tell us
V
about the
unmarried
children of
the veteran

NOTE: Skip to Section VI if you are claiming benefits for any children that meet the
following criteria.
VA recognizes the veteran’s biological children, adopted children, and stepchildren as dependents.
These children must be unmarried and:

...

under age 18, or

Note: You should provide a
at least 18 but under 23 and pursuing an approved course of education, or
copy of the public record of birth
of any age if they became permanently unable to support themselves before
or a copy of the court record of
reaching age 18.
adoption for each
child listed in Item 28a unless the
"Seriously disabled" (Item 29e) means that the child became permanently unable to support
veteran was receiving addtional
himself/herself before reaching age 18. Furnish a statement from an attending physician or
VA benefits for the child.

other medical evidence which shows the nature and extent of the physical or mental impairment.

If you need additional space,
please attach a separate sheet
of paper providing the requested
information about each child.

28. Name of child
(First, middle initial,
Last)

Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over age
18 is entitled to receive DIC benefits in his or her own right. A veteran’s child who is seriously
disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.

28b. Date and place
of birth (City/State
or Country)

(mo

day yr)

(mo

day yr)

(mo

day yr)

28c. Social Security
Number

29a.
Biological

29b.
Adopted

29c.
Stepchild

29d.
18-23 yrs
old and in
school

29e.
Seriously
disabled

21-534

29f.
Child
previously
married

PAGE 3

SECTION V Tell us about the unmarried children of the veteran (continued)
Tell us about the children listed above that don’t live with you.
30a. Name of child
(first, middle initial, last)

30b. Child’s Complete Address

30c. Name of person the child
lives with (If applicable)

30d. Monthly amount you
contribute to child’s
support
$
$
$
$

SECTION Tell us if
VI you are
housebound
in a nursing
home or
require aid
and
attendance

31. Are you claiming aid and attendance allowance
and/or housebound benefits because you need the
regular assistance of another person, are having
severe visual problems, or are housebound?
YES

NO

(If "No," skip to section VII)

If you answered "yes" to Item 31 32b. What is the name and complete mailing address
of the facility?
and are not in a nursing home,
submit a statement from your
doctor showing the extent of
your disabilities. If you are in a
nursing home, attach a statement
signed by an offficial of the
nursing home showing the date
you were admitted to thenursing 32d. Have you applied for Medicaid?
home, the level of care you
YES
NO
receive, the amount you pay
out-of-pocket for your care, and
whether Medicaid covers all or
part of your nursing home costs.

32a. Are you now in a nursing home?

YES

NO

(If "Yes," answer Items 32b and 32c also)

32c. Does Medicaid cover all or part of your
nursing home costs?

YES

NO

(If "No," answer Item 32d also)

21-534

PAGE 4

SECTION Tell us the net
VII
worth of you
and your
dependents
Note: If you are filing this application on
behalf of a minor or incompetent child of
the veteran and you are the child’s
custodian, you must report your
net worth as well as the net worth of
the child for whom benefits are claimed.

VA cannot pay you pension if your net worth is sizeable. Net worth is the market value of
all interest and rights you have in any kind of property less any mortgages or other claims
against the property. However, net worth does not include the house you live in or a
reasonable area of land it sits on. Net worth also does not include the value of personal
things you use everyday like your vehicle, clothing, and furniture. You must report net
worth for yourself and all persons for whom you are claiming benefits.

For Items 33a through 33f, provide the amounts. If none, write "0" or "None."

Child(ren)
Source

Surviving spouse or
Custodian of children

Name:

Name:

Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

33a. Cash, bank accounts,
certificates of deposit (CDs)
33b.IRAs, Keogh Plans, etc.
33c. Stocks, bonds, mutual funds
33d. Value of business assets
33e. Real Property (not your home)
33f. All other property

SECTION Tell us about
VIII
the income of
you and your
dependents
Payments from any source will be
counted, unless the law says that they
don’t need to be counted. Report all
income, and VA will determine any
amount that does not count.
Note: If you are filing this application on
behalf of a minor of whom you
are the custodian, you must report your
income as well as the income of each
child for whom benefits are claimed.

Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same information in both tables.
if you expect to receive a payment, but you don’t know how much it will be, write
"Unknown" in the space.
If you do not receive any payments from one of the sources that we list, write "0" or
"None" in the space.
If you are receiving monthly benefits, give us a copy of your mst recent award letter.
This will help us determine the amount of benefits you should be paid.
34a. Have you claimed or are you receiving
benefits from the Social Security
Administration on your own behalf or on
behalf of child(ren) in your custody?
YES

NO

(If "Yes," answer Item 34b)
35. Has a surviving spouse or child filed a claim
for compensation from the Office of
Worker’s Compensation Programs based on
the death of the veteran?
YES

NO

34b. Is Social Security based on your own
employment?

YES

NO

36. Has a court awarded damages based on
the death of the veteran or is a claim or
legal action for damages pending?

YES

NO

37. Have you claimed or are you receiving Survivor Benefit Plan (SBP) annuity from a service
department based on the death of the veteran?
YES

NO

21-534

PAGE 5

SECTION VIII Tell us about the income of you and your dependents (continued)
Monthly Income - Tell us the income you and your dependents receive every month

Child(ren)
Source

Surviving spouse or
Custodian of children

Name:

Name:

Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

38a. Social Security
38b. U.S. Civil Service
38c. U.S. Railroad Retirement
38d. Military Retirement
38e. Black Lung Benefits
38f. Supplemental Security Income
(SSI)/ Public Assistance
38g. Other income received monthly
(Please write source below:)

Expected income next 12 months - Tell us about other income for you and your dependents
Report expected income for the 12 month period following the veteran’s death. If the claim is filed more than one year after the veteran
died, report the expected income for the 12 month period from the date you sign this application.

Child(ren)
Sources of income
for the next 12
months

Surviving spouse or
Custodian of children

Name:

Name:

Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

39a. Gross wages and salary
39b. Total dividends and interest
39c. Other income expected
(Please write source below:)

39d. Other income expected
(Please write source below:)

21-534

PAGE 6

SECTION IX
Family medical expenses and certain other expenses actually paid by you may be deductible from your
income. Show the amount of any continuing family medical expenses such as the monthly Medicare deduction
or nursing home costs you pay. Also, show unreimbursed last illness and burial expenses and educational or
vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed amounts paid
by you for the veteran’s or his/her child’s last illness and burial and the veteran’s just debts. Educational or
vocational rehabilitation expenses are amounts paid for courses of education, including tuition, fees, and
materials. Do not include any expenses for which you were reimbursed. If you receive reimbursement after
you have filed this claim, promptly advise the VA office handling your claim. If more
space is needed attach a separate sheet.

Tell us about medical,
last illness, burial or
other unreimbursed
expenses

40a. Amount paid by you

40b. Date Paid

$

(mo

day yr)

$

(mo

day yr)

$

(mo

day yr)

$

(mo

day yr)

SECTION X
Give us direct
deposit information

If benefits are awarded we will
need more information in order
to process any payments to you.
Please read the
paragraph starting with,
"All Federal payments......"
and then either:

40c. Purpose (Medicare
deduction, nursing
home costs, burial
expenses, etc.)

40d. Paid to (Name of nursing
home, hospital, funeral
home, etc,

40e. Relationship of person for whom
expenses paid

All Federal payments beginning January 2, 1999, must be made by electronic furnds transfer (EFT) also called
Direct Deposit. Please attch a voided personal check or deposit slip or provide the information requested below
in Items 41, 42, and 43 to enroll in Direct Deposit. If you do not have a bank account we will give you a
waiver from Direct Deposit, just check the box below in Item 41. The Treasury Department is working on
making bank accounts available to you. Once these accounts are available, you will be able to decide whether
you wish to sign-up for one of the accounts or continue to receive a paper check. You can also request a waiver
if you have other circumstances that you feel would cause you a hardship to be enrolled in Direct Deposit. You
can write to: Department of Veterans Affairs, 125 S. Main Street Suite B, Muskogee OK 74401-7004, and give
us a brief description of why you do not wish to participate in Direct
Deposit.
41. Account number (Please check the appropriate box and provide that account number, if applicable)
Checking

I certify that I do not have an account with a financial
institution or certified payment agent

Savings

1. Attach a voided check, or
Account number

2. Answer questions 41-43
to the right.

42. Name of financial institution

43. Routing or transit number

21-534

PAGE 7

SECTION Give us
XI
your
signature

I certify and authorize the release of information:
I certify that the statements in this document are true and complete to the best of my knowledge. I authorize
any person or entity, including but not limited to any organization, service provider, employer, or government
agency, to give the Department of Veterans Affairs any information about me except protected health
information, and I waive any privilege which makes the information confidential.
44. Your signature

SECTION
XII

45. Today’s date

46a. Signature of witness (If claimant signed above
using an "X")

46b. Printed name and address of witness

47a. Signature of witness (If claimant signed above
using an "X")

47b. Printed name and address of witness

48. 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.

21-534

PAGE 8

Form Approved
OMB Approved No. 0960-0062

SOCIAL SECURITY ADMINISTRATION

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

APPLICATION FOR SURVIVORS BENEFITS
(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)
IMPORTANT - Read instructions before completing form. Detach and retain ONLY the instruction sheet.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

NOTE: If the veteran’s Social Security No. is unknown, complete Items 4,5, 6 and 7 about veteran.
3. SOCIAL SECURITY NO. OF VETERAN

4. DATE OF BIRTH

6. NAME OF FATHER

5. PLACE OF BIRTH

7. MAIDEN NAME OF MOTHER

8. DID THE VETERAN WORK IN THE RAILROAD INDUSTRY
AT ANY TIME AFTER 1936?
YES

NO

NOTE: The following information should be furnished for each period of the veteran’s active service (regular or reserves) after September 7, 1939, in
the military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric
Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.
9A. DATE ENTERED ACTIVE SERVICE

9B. SERVICE NO.

10. RELATIONSHIP OF APPLICANT TO VETERAN
SURVIVING SPOUSE

CHILD

9C. DATE SEPARATED FROM ACTIVE
SERVICE

9D. GRADE, RANK, OR RATING, ORGANIZATION
AND BRANCH OF SERVICE

11. DATE OF BIRTH OF APPLICANT 12. VA FILE NO.

PARENT

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (inluding
stepgrandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c)
disabled or handicapped (18 or over and disability began before age 22).
13A.

13B.

13C.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a
right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information
I have given in this document is true.
14. DATE (Month, day, year)

15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in Ink)

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code)

17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
20. PROOFS RECEIVED
DEATH

21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)
MARRIAGE

DEATH

MARRIAGE

AGE

(NAME)

AGE

(NAME)

OTHER (Specify)

(NAME)

OTHER (Specify)

(NAME)

(NAME)
22. DATE

(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (2-2002) Destroy All Prior Editions

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IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)

This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the
Social Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the
application requests information in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete
part or all of the SSA-24. However, it is usually to your advantage to provide the information because
not providing it could prevent an accurate and timely decision on your claim or could result in the loss of
some benefits or insurance coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to
the Social Security Administration and used by them to determine wheter social security benefits may be
payable to surviving dependent(s) of the veteran. Social Security will then contact you regarding any
social security benefits payable based on information given on this form.
Please understand that Social Security may, in certain instances, disclose the information on this form to
another Federal, State or local agency or individual without your written consent. This would be done in
order to:

.
.
.

enable a third party or an agency to assist Social Security in establishing an individual’s
right to benefits or coverage;
comply with Federal laws which require or authorize the release of information from social
security records; and
facilitate statistical research and audit activities necessary to assure the integrity and
improvement of the social security programs.

If you should have any question about entitlement to social security benefits or the information you have
provided on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When
signed and dated the form SHOULD BE LEFT ATTACHED to your completed

.
.

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)

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of
44 U.S.C. ss3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take you about 15 minutes to read the instructions, gather the necessary
facts, and answer the questions.

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