Form VA Form 21-4103 VA Form 21-4103 Information From Remarried Widower

INSTRUCTIONS FOR
INFORMATION FROM REMARRIED WIDOW/ER
VA FORM 21-4103
NOTE: Read very carefully, detach, and keep this instruction sheet for your reference.
A. How can I contact VA if I have questions?

Income

If you have questions about this form, how to fill it out, or
about benefits, contact your nearest VA regional office. You
can locate the address of the nearest regional office in your
telephone book blue pages under "United States Government,
Veterans" or call 1-800-827-1000 (Hearing Impaired TDD
line 1-800-829-4833). You may also contact VA by Internet
at http://www.vba.va.gov/benefits/address.htm.

Payments from any source will be counted, unless the law says
that they don't need to be counted. Report all income, and VA
will determine any amount that does not count. Be sure to
report the total amounts before you take out deductions for
taxes, insurance, etc. If you expect to receive a payment, but
you don't know how much it will be, write "unknown" in the
space. If you do not receive any payments from one of the
sources that we list, write "0" or "none" in the space.

B. What is the purpose of VA Form 21-4103?
If a surviving spouse is no longer eligible to receive death
pension, use VA Form 21-4103 to apply for death pension on
behalf of a child or children of the veteran.
C. Who may be eligible for death pension?
Pension may be paid for the veteran's biological children,
adopted children, and stepchildren. But these children must be
unmarried and:
under age 18, or
between 18 and 23 and pursuing an approved course of
education, or
of any age if they became permanently unable to support
themselves before reaching age 18.
If any child is claimed as permanently unable to support
themselves before reaching age 18, furnish a statement from
an attending physician or other medical evidence which shows
the nature and extent of the physical or mental impairment.
If a child who is receiving death pension marries, then VA
will no longer pay pension. However, VA may begin paying
pension again if the child's marriage is terminated.
D. How does VA decide whether or not a child is eligible
to receive death pension?
VA pays pension based on the amount of income and net
worth of the child or children and the person or persons legally
responsible for the child's or children's support. This is based
on law. VA must include as income all sources that federal
law specifies. You can find out what the current income
limitations and rates of benefits are by contacting your nearest
VA office.

VA FORM
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21-4103

Net Worth
Net worth is the market value of all interest and rights you,
your spouse and the child(ren) have any kind of property less
any mortgages or other claims against the property. However,
net worth does not include the house you live in or a
reasonable area of land it sits on. Net worth also does not
include the value of personal things used everyday like your
vehicle, clothing, and furniture. The net worth must be
reported for the person legally responsible for the child(ren)'s
support and all child(ren) for whom benefits are claimed.
In order to determine entitlement to pension, the surviving
spouse must report:
All his/her income and net worth, and
All the income and net worth of his/her spouse from the
date of remarriage, and
All the income and net worth of each child for whom
benefits are claimed.
E. How do I complete my application?
Print all answers clearly. If an answer is "none" or "0," write
that. Your answer to every question is important to help us
complete your claim. If you do not know the answer, write
"unknown." For additional space, use Item 13, "Remarks," or
attach a separate sheet, indicating the item number to which
the answers apply. Make sure you sign and date this
application.
F. What do I do when I have completed my application?
When you have completed this application mail it or take it to
a VA regional office. Be sure to attach any materials that
support and explain your claim. Also, make a photocopy of
your application and everything that you submit to VA before
you mail it.

EXISTING STOCK OF VA FORM 21-4103, JUN 2011,
WILL BE USED.

OMB Control No. 2900-0038
Respondent Burden: 20 Minutes
Expiration Date: XXXXXXXX

INFORMATION FROM REMARRIED WIDOW/ER
Privacy Act Notice: 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) 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 eligibility for 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 determine eligibility for death pension for a veteran's child or children (38 U.S.C. 1542). Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send
comments or suggestions about this form.

IMPORTANT - Please read the instructions before completing this form.
2. VA FILE NUMBER

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

XC-

PART I - INFORMATION REGARDING WIDOW/ER

3. FIRST NAME - MIDDLE NAME - LAST NAME OF WIDOW/ER

4. ADDRESS (Number and street or rural route, city, State and ZIP Code)

5. DATE REMARRIED (Month, day, year)

6. PLACE REMARRIED (City and State)

7A. DAYTIME TELEPHONE NO. (Including Area Code)

7B. EVENING TELEPHONE NO. (Including Area Code)

PART II - INFORMATION REGARDING CHILD/REN OF VETERAN

8A. NAME AND ADDRESS OF CHILD

8B. NAME AND ADDRESS OF PERSON HAVING CUSTODY

PART III - NET WORTH
NOTE: If you have no income or net worth from a particular source, write "0" or "none." Do not leave any items blank.
AMOUNTS

ITEM
NO.
9A.
9B.

SOURCE

WIDOW/ER

STOCKS, BONDS, BANK
$
DEPOSITS
REAL ESTATE

SPOUSE

NAME OF CHILD/REN

$

$

$

$

$

$

$

$

(Do not include residence)

9C.

OTHER PROPERTY

9D.

TOTAL DEBTS

9E.

NET WORTH

VA FORM
XXX 2014

21-4103

$

EXISTING STOCK OF VA FORM 21-4103, JUN 2011,
WILL BE USED.

PART IV - ANNUAL INCOME
NOTE: If you have no income or net worth from a particular source, write "0" or "none." Do not leave any items blank.
AMOUNTS
ITEM
NO.

SOURCE

WIDOW/ER

SPOUSE

NAME OF CHILD/REN

(Income from date
of marriage)

AMOUNT RECEIVED FROM JANUARY 1 TO DATE WIDOW/ER REMARRIED
10A.

EARNINGS

10B

SOCIAL SECURITY

10C.

OTHER ANNUITIES AND RETIREMENTS

10D.

DIVIDENDS, INTEREST, ETC.

10E.

OTHER INCOME (Specify source)

10F.

OTHER INCOME (Specify source)

AMOUNT EXPECTED FROM DATE WIDOW/ER REMARRIED THROUGH END OF CALENDAR YEAR
11A.

EARNINGS

11B.

SOCIAL SECURITY

11C.

OTHER ANNUITIES AND RETIREMENTS

11D.

DIVIDENDS, INTEREST, ETC.

11E.

OTHER INCOME (Specify source)

11F.

OTHER INCOME (Specify source)

AMOUNT EXPECTED NEXT CALENDER YEAR
12A.

EARNINGS

12B.

SOCIAL SECURITY

12C.

OTHER ANNUITIES AND RETIREMENTS

12D.

DIVIDENDS, INTEREST, ETC.

12E.

OTHER INCOME (Specify source)

12F.

OTHER INCOME (Specify source)

13. REMARKS (Use this space for any additional information regarding this claim)

CERTIFICATION: I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
14. SIGNATURE

15. DATE SIGNED

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 fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-4103, XXX 2014