VA Form 21-534a Application for Dependency and Indemnity Compensation by

OMB. Approved No. 2900-0004
Respondent Burden: 15 minutes

APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION
BY A SURVIVING SPOUSE OR CHILD - IN-SERVICE DEATH ONLY
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 1.526 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. 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 service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 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.
1. VETERAN’S FIRST - MIDDLE- LAST NAME

2. VETERAN’S SOCIAL SECURITY NO.

3. CLAIMANT’S FIRST - MIDDLE- LAST NAME

4. CLAIMANT’S SOCIAL SECURITY NO.

NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other
service-connected death benefits to which you and/or the deceased veteran’s children may be entitled.
5. FOR SURVIVING SPOUSE ONLY: I
have
have not lived continuously with the veteran from date of marriage to date of death.
If not, answer Item 6.
6. CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order,
attach a copy of such order.)

7. DATE OF BIRTH OF SURVIVING
SPOUSE (Mo., Day, Yr.)

8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
PLACE OF BIRTH
(City and State)

DATE OF BIRTH SOCIAL SECURITY
(Mo., Day, Yr.)
NUMBER

FULL NAME

RELATIONSHIP TO CLAIMANT

9. CLAIMANT’S CURRENT MAILING ADDRESS

10. CLAIMANT’S TELEPHONE NUMBERS (Including Area Code)
DAYTIME
EVENING

11. I

will

will not

be changing my address.

12. CLAIMANT’S NEW ADDRESS

14. I

want

do not want

15. ACCOUNT
CHECKING
SAVING

13. DATE OF ADDRESS CHANGE

my VA payment to be directly deposited to my financial account.
ACCOUNT NUMBER________________________________________
FINANCIAL INSTITUTION’S NINE-DIGIT ROUTING OR TRANSIT NUMBER
_________________________________________

I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
17. DATE SIGNED

16. SIGNATURE OF CLAIMANT

18. NAME AND RANK OF MILITARY
CASUALTY ASSISTANCE OFFICER (CAO)

19. TELEPHONE NUMBER OF CAO

20. E-MAIL ADDRESS OF CAO

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 to which you are not entitled.
VA FORM
MAR 2004

21-534a

INSTRUCTIONS FOR VA FORM 21-534a
PRINT ALL ANSWERS CLEARLY.
SIGN AND DATE THE APPLICATION.
MAKE A PHOTOCOPY OF THIS APPLICATION AND EVERYTHING YOU SUBMIT TO
VA BEFORE YOU MAIL IT.
NOTE - All the information requested must be answered fully and clearly or action on your
claim may be delayed. If you do not know the answer, write "unknown."
SPECIFIC INSTRUCTIONS
ITEMS 1-2 - Self-explanatory.
ITEM 3 - Name of surviving spouse or person applying on behalf of minor children.
ITEMS 4-12 -Self-explanatory.
ITEM 13 - Expected date that new mailing address will be effective.
ITEMS 14-17 - Self-explanatory.
ITEMS 18-20 - To be completed by Military Casualty Assistance Officer.
MINORS AND INCOMPETENT PERSONS - If the person for whom the claim is being made is
a minor or incompetent person, the application 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.
THIS FORM, ALONG WITH THE SERVICEMEMBER’S DD FORM 1300, REPORT OF
CASUALTY, SHOULD BE MAILED OR FAXED TO:
DEPARTMENT OF VETERANS AFFAIRS
REGIONAL OFFICE AND INSURANCE CENTER
P.O. BOX 8079
PHILADELPHIA, PA 19101
FAX NUMBER (215) 381-3084.

For assistance in completing this application, or information about VA benefits and services, call
us toll-free at 1-800-827-1000 (Hearing Impaired--TDD Line 1-800-829-4833).