VA Form 21-0820a Report of Death of Veteran/Beneficiary

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

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

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. NAME OF PERSON WHO CONTACTED YOU

7. TYPE OF CONTACT (Check)
PERSONAL
9. TELEPHONE NUMBER OF PERSON
WHO CONTACTED YOU (Include Area Code)

8. ADDRESS OF PERSON WHO CONTACTED YOU

(

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

)

FNOD
I identified myself as a VA employee who is authorized to receive information (38 CFR 3.217)

A. NAME OF DECEASED

11. IDENTIFYING INFORMATION
B. RELATIONSHIP TO VETERAN

C. DATE OF DEATH (Month, day, year)

VETERAN
SURVIVING SPOUSE
SURVIVING CHILD
OTHER_____________________
D. IF THE DECEASED IS THE VETERAN DID HE/SHE DIE AT A VA FACILITY
YES

NO (If, "Yes," provide name, city and state _____________________________________
________________________________________________________________________

E. NAME OF VETERAN’S SURVIVING DEPENDENT(S) (If any)

F. SURVIVING DEPENDENTS(S) ADDRESS & PHONE NUMBER (If needed)

12. DEATH OF VETERAN - FNOD ACTION
ADVISED CALLER THAT THE BENEFITS WILL BE STOPPED THE FIRST OF THE MONTH OF DEATH
REVIEWED VETERAN’S RECORD
ANSWERED QUESTIONS CONCERNING POSSIBLE BENEFIT ENTITLEMENTS REFERRING TO "DEATH RELATED INFORMATION CHECKLIST" WORK AID
PROCESSED VETERAN’S FNOD IN SHARE
YES
SENT:

NO (If, "No," explain______________________________________________________________________________________________
PMC

NOK LETTER

21-530

21-534

40-1330

OTHER (Please specify)__________________________________________)

13. DEATH OF A NON-VETERAN BENEFICIARY - FOR STOP PAYMENT ACTION
CLAIMS FILE LOCATION_________________________________________________
ADVISED CALLER THAT THE CHECK ISSUED FOR THE MONTH IN WHICH THE BENEFICIARY DIED WILL HAVE TO BE RETURNED, OR
IN THE CASE OF DIRECT DEPOSIT WILL BE RECOVERED FROM THE BENEFICIARY’S ACCOUNT.
ADVISED CALLER OF POSSIBLE BURIAL OF SPOUSE/CHILD IN NATIONAL CEMETERY PER http://www.cem.va.gov/cem/pdf/burialin.pdf
ROUTED THIS REPORT OF DEATH TO REGIONAL OFFICE OF JURISDICTION VIA ENCRYPTED E-MAIL FOR STOP PAYMENT PROCESSING
DIVISION OR SECTION

EXECUTED BY (Signature and Title)

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, 58VA/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

21-0820a