27-0820f Report of Month of Death

OMB Control No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

REPORT OF MONTH OF DEATH
NOTE - This form must be filled out in ink or on a typewriter or
computer, as it becomes a permanent record in the veteran's folder.
3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6. TELEPHONE NUMBER OF VETERAN (Include Area Code)

7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT

1. VA OFFICE

4. DATE OF CONTACT (Month, day, year)

PERSONAL

TELEPHONE

9. ADDRESS OF PERSON CONTACTED

10A. TELEPHONE NUMBER OF PERSON CONTACTED (Include Area Code)

10B. E-MAIL ADDRESS OF PERSON CONTACTED (If applicable)

11. ACTION TO BE COMPLETED BY PCR

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN

The surviving spouse is claiming the month of death benefit based on the above named veteran.
A. NAME (If different than above)

INFORMATION REGARDING THE SURVIVING SPOUSE
B. DATE OF BIRTH (Month, day, year)

C. SOCIAL SECURITY NUMBER

D. ADDRESS (If different than above)

I certify I read the following 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."

cc to Surviving Spouse's POA (If applicable)
DIVISION OR SECTION

EXECUTED BY (Signature and title)

DATE

12. ACTION TO BE TAKEN BY VSC
The surviving spouse is entitled to the one-time payment of $
, the monthly compensation
or pension amount received by the veteran at the time of his/her death per 38 CFR 3.20 (c)
and M21-1MR IV.iii.3.b.12.
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, 58/21/22/28 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 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.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.
VA FORM
XXX 20XX

27-0820f

SUPERSEDES VA FORM 27-0820F, APR 2013, WHICH
WILL NOT BE USED.