VA Form 21-0820f Report of Contact - Month of Death Claim

OMB Control No. 2900-XXXX
Respondent Burden: 5 minutes

REPORT OF CONTACT - MONTH OF DEATH CLAIM
NOTE - This form must be filled out in ink or on a typewriter/computer, 1. VA OFFICE
as it becomes a permanent record in the veteran’s folder.

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6. TELEPHONE NUMBER OF VETERAN (Include Area Code)

7. PERSON CONTACTED (Indicate if surviving spouse)

(
)
9. ADDRESS OF PERSON CONTACTED

8. TYPE OF CONTACT (Check)

PERSONAL
10A. TELEPHONE NUMBER OF PERSON CONTACTED (Include Area Code)
(

TELEPHONE
10B. E-MAIL ADDRESS OF PERSON CONTACTED (If applicable)

)

11. MONTH OF DEATH CLAIM
ACTION TO BE COMPLETED BY PCR
A. VA EMPLOYEE IDENTIFIED HIMSELF/HERSELF AS A PERSON WHO IS AUTHORIZED TO RECEIVE THE INFORMATION OR STATEMENT
(38 CFR 3.217)
CC: TO SURVIVING SPOUSE’S POA (If applicable)
B. VA EMPLOYEE VERIFIED THE IDENTITY OF THE CLAIMANT THROUGH THE FOLLOWING SPECIFIC INFORMATION PER 38 CFR 3.217
SURVIVING SPOUSE’S FULL NAME
VETERAN’S SOCIAL SECURITY NUMBER/CLAIM NUMBER
(Recorded above in Item 7)
VETERAN’S FULL NAME
SURVIVING SPOUSE’S SOCIAL SECURITY NUMBER
VETERAN’S BRANCH OF SERVICE
C. THE SURVIVING SPOUSE IS CLAIMING THE MOD BENEFIT BASED ON THE ABOVE NAMED VETERAN AND THE FOLLOWING
DEPENDENCY INFORMATION
DATE OF BIRTH (month, day,
CURRENT ADDRESS AND PHONE NUMBER (Recorded above in Items 5 & 6)
NUMBER OF TIMES VETERAN HAS BEEN MARRIED ___________________

INFORMATION REGARDING VETERAN’S PRIOR MARRIAGES
DATE OF MARRIAGE
(Month,Year)

PLACE OF MARRIAGE
(City/state or country)

TO WHOM MARRIED

HOW MARRIAGE ENDED
(Death, divorce)

DATE AND PLACE OF TERMINATION OF
MARRIAGE
(Month,Year) (City/state or country)

NUMBER OF TIMES SURVIVING SPOUSE HAS BEEN MARRIED ___________________
INFORMATION REGARDING SURVIVING SPOUSE’S PRIOR MARRIAGES
DATE OF MARRIAGE
(Month,Year)

PLACE OF MARRIAGE
(City/state or country)

TO WHOM MARRIED

HOW MARRIAGE ENDED
(Death, divorce)

DATE AND PLACE OF TERMINATION OF
MARRIAGE
(Month,Year) (City/state or country)

ACTION TO BE TAKEN BY VSC
The surviving spouse is entitled to the one-time payment of $______________________, the monthly compensation or pension amount received by the veteran at time
of his/her death per 38 CFR 3.20 (c) and M21-1MR IV.iii.3.b.12.
VSR SIGNATURE

DATE

SR. VSR SIGNATURE

DATE

ACTION TO BE TAKEN BY FINANCE
MOD CHECK ISSUED TO SURVIVING SPOUSE (06A transaction)
Note - return the VA form 21-0820f to VSC to clear EP

ACTION TO BE TAKEN BY VSC
EP CLEARED BY

DATE

EXECUTED BY (Signature and Title of PCR)

I read the following summary of the Privacy Act statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA benefits. The primary
purpose for gathering this information or statement is to make an eligibility determination. It is subject to verification through computer matching programs with other
agencies."
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 1.576 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, 58/21/22/28 Compensation, Pension, Education and Vocational
Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 obtain evidence in support of your claim for benefits (38 U.S.C. 501(a) and (b)). Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 5 minutes to respond to the questions on this form. VA cannot conduct or sponsor a
collection of information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/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.

VA FORM
NOV 2008

21-0820f