Form 21-0537 Marital Status Questionnaire

You are receiving dependency and indemnity compensation (DIC) as the surviving spouse of a veteran
who died in service or from service-connected conditions. Generally, a surviving spouse’s entitlement
to DIC ends with remarriage. If a surviving spouse remarries, entitlement may continue provided the
marriage began after age 57 or has been terminated. You are responsible for reporting any change in
your marital status.
We need to verify your marital status. Please answer the questions below.
If you do not return this letter with your answers to VA within 60 days of the date shown above, we
will stop your DIC benefits. After answering the questions below, please return this letter in the
enclosed envelope. Be sure to place it in the envelope so that the return address of the regional office
shows through the envelope window.
You have the right at any time to submit additional information or to have a personal hearing to explain
or clarify your statements. You also have the right to be represented at the hearing by a representative
of your choice.
If You Have Questions or Need Assistance
If you have any questions, you may contact us by telephone, e-mail, or letter.
If you:

Here is what to do:

Telephone

Call us at 1-877-294-6380. If you use a Telecommunications Device
for the Deaf (TDD), the number is 1-800-829-4833.

Use the Internet

Send electronic inquiries through the Internet at https://iris.va.gov .

Write

Put your full name and VA file number on the letter. Please send all
correspondence to the address at the top of this letter.

Sincerely yours,

Pension Management Center Manager
Enclosure

(See Reverse)
VA FORM
APR 2010

21-0537

OMB Approved No. 2900-0495
Respondent Burden: 5 minutes

MARITAL STATUS QUESTIONNAIRE
PRIVACY ACT INFORMATION: Payment of death benefits cannot be made unless the information requested is furnished as required by existing law (38 U.S.C. 101(3)).
The responses you submit are considered confidential, (38 U.S.C. 5701). They may disclosed outside the Department of Veterans Affairs only if the disclosure is
authorized by the Privacy Act, including the routine uses identified in the system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation Records - VA, 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. information submitted is subject to verification through computer matching programs
with other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it display a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments
regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your comments.

1A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
YES

NO

1B. DATE OF MARRIAGE

(If "Yes," please provide the date in Item 1B, the name of your spouse in Item 1C,
and your spouse’s date of birth in Item 1D)

1C. NAME OF SPOUSE

1D. SPOUSE DATE OF BIRTH

2A. HAS YOUR REMARRIAGE BEEN TERMINATED?
NO (If "Yes," please provide the date in Item 2B and the reason for termination (i.e., death, divorce) in Item 2C)
YES
2B. DATE OF TERMINATION
2C. REASON FOR TERMINATION

3. TELEPHONE NUMBER (Include Area Code)
A. EVENING

A. DAY TIME

4. E-MAIL ADDRESS

5A. SIGNATURE

VA FORM
APR 2010

5B. DATE SIGNED

21-0537