Form VA Form 21-0847 VA Form 21-0847 Request for Substitution of Claimant upon Death of Claim

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE REQUEST FOR
SUBSTITUTION OF CLAIMANT UPON DEATH OF CLAIMANT

GENERAL INFORMATION
38 U.S.C. section 5121a, Substitution in case of death of claimant. It provides that if a claimant dies while a
claim or appeal for any benefit under a law administered by the Secretary is pending, a living person who
would be eligible to receive accrued benefits due to the claimant under section 5121(a) of this title may, not
later than one year after the date of the death of the claimant, request to be substitute as the claimant for
the purposes of processing the claim to completion.
The new statute allows a person who could be considered an accrued benefits claimant to substitute for a
deceased claimant to continue adjudication of the deceased claimant’s claim.

SPECIFIC INSTRUCTIONS
Section 1
In this section, give us the pertinent identifying information to include name, claim and/or social security
numbers, and date of birth of the veteran.

Section 2
Provide us with the substituting claimants’ pertinent contact information to include name, address, contact
numbers, and mail address.

Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our
Internet website at http://www.va.gov/directory or in the government pages of your telephone book under
"United States Government, Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA.

WHAT IF I CHANGE MY MIND?
If you change your mind and do not want to be the substitute for the deceased claimant, write us a letter to
revoke your request.

VA FORM
JUN 2009

21-0847

OMB Approved No. 2900-XXXX
Respondent Burden: 5 minutes
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

REQUEST FOR SUBSTITUTION OF CLAIMANT UPON
DEATH OF CLAIMANT
INSTRUCTIONS: Use this form if you want to request to substitute the claim of a deceased claimant.
SECTION I - VETERAN’S IDENTIFYING INFORMATION
1. FIRST, MIDDLE, LAST NAME OF DECEASED CLAIMANT (Print clearly)

3. VETERAN’S SOCIAL SECURITY NUMBER

2. VETERAN’S CLAIM NUMBER

5. VETERAN’S DATE OF DEATH (Month, day, year)

4. VETERAN’S DATE OF BIRTH (Month, day, year)

SECTION II - SUBSTITUTE CLAIMANT INFORMATION
I have interest in the claim of the deceased and request to be substituted as the claimant. I am eligible to receive
accrued benefits due the deceased claimant and I am eligible to be a substitute claimant under section 5121(a) of
title 38.
6. FIRST, MIDDLE, LAST NAME OF SUBSTITUTE CLAIMANT NAME (Print clearly)

7. RELATIONSHIP TO DECEASED

8. CLAIMANT’S SOCIAL SECURITY NUMBER

9. ADDRESS OF CLAIMANT (No. and Street or rural route, City or P.O., State and ZIP Code)

10. CLAIMANT’S TELEPHONE NUMBER(S)
A. DAYTIME PHONE NUMBER

11. E - MAIL ADDRESS (If applicable)

B. EVENING PHONE NUMBER

B. CELL PHONE NUMBER

12. FAX NUMBER (If applicable)

13. REMARKS

14A. SIGNATURE (Do NOT print)

14B. DATE SIGNED

PRIVACY ACT INFORMATION: 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, 58VA21/22/28 Compensation,
Pension, Education, and Vocational Rehabilitation and Employment 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. 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 substitution benefits under 38 U.S.C. 5121(a). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 5 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.
VA FORM
JUN 2009

21-0847