Form VA Form 21P-601 VA Form 21P-601 Application for Accrued Amounts Due a Deceased Beneficia

INSTRUCTIONS FOR VA FORM 21P-601
APPLICATION FOR ACCRUED AMOUNTS DUE A DECEASED BENEFICIARY
Note: Do not complete this form if you have applied for death benefits by using VA Form 21P-534 or 21P-535. Read very
carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
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
1-877-294-6380 (Hearing Impaired TDD line 711.) You may also contact VA by Internet at http://iris.va.gov.
B. What do I use VA Form 21P-601 for?
Use VA Form 21P-601 to apply for accrued benefits due the beneficiary but not paid prior to death. Each person claiming a share of
accrued benefits must complete a separate VA Form 21P-601.
Note: If you are a deceased veteran's surviving spouse, child, or dependent parent, you may apply for death benefits, including
accrued benefits, using VA Form 21P-534EZ, Application for DIC, Death Pension and/or Accrued Benefits.
C. What are accrued benefits and how does VA decide what I will or will not receive?
Accrued benefits are benefits that were due the beneficiary at the time of death but not paid prior to death. Entitlement to accrued
benefits is determined according to the line of succession established by law.
A person eligible for accrued benefits may request to substitute for a deceased claimant who had a pending claim or appeal at the time
of his or her death. Substitution allows a person to submit evidence in support of the pending claim or appeal for potential accrued
benefits.
The right to substitute may be waived by marking "yes" in the designated box on this form. If the right to substitute is waived, VA
may still consider the accrued claim, however, will do so based only on the evidence contained in the claims folder at the time of
death.
Any available accrued benefits are payable to the first living person listed below. The fact that a preferred beneficiary fails to file or
prosecute a claim does not permit payment of his/her share of accrued benefits to a person or persons having an equal or lower
preference. A waiver of right also does not permit such payment. If there are no living persons who are entitled on the basis of
relationship, accrued benefits may be payable as reimbursement for last illness and burial expenses (see Paragraph D.)
When the deceased beneficiary is a
veteran, accrued is payable

When the deceased beneficiary is a
surviving spouse, accrued is payable

in full to the surviving spouse, or
in equal shares to the veteran's children (see
definition of "child" below), or

in equal shares to the veteran's
children (see definition of
"child" below).

in equal shares to the veteran's parents, if
they are dependent upon the veteran at the
date of the veteran's death, or

When the deceased beneficiary is a
child, accrued is payable
in equal shares to the veteran's
children who are entitled to death
compensation, dependency and
indemnity compensation, or death
pension (see definition of "child"
below).

in full to the sole surviving parent, if he/she
is dependent upon the veteran at the date of
the veteran's death.
Definitions:
Child means an unmarried child of the veteran who is under 18 years of age, or at least 18 but under 23 years of age and pursuing an
approved course of education, or became incapable of self support prior to reaching age 18. However, benefits may be payable to the
veteran's children, regardless of age or marital status, if lump sum accrued benefits are payable.
Lump sum accrued benefits are amounts withheld from a competent veteran's Old Law Pension benefits (fixed rate since 1960)
during hospital treatment, or institutional or domiciliary care.
VA FORM
XXXXX

21P-601

SUPERSEDES VA FORM 21P-601, SEP 2015,
WHICH WILL NOT BE USED.

D. Who may file a claim for reimbursement for last illness and burial expenses?
If there are no living persons who are entitled on the basis of relationship, accrued benefits may be used to reimburse the person or
persons who paid for or are responsible to pay the expenses of last illness and burial of a beneficiary. The claim should be filed by the
person or persons whose funds were or will be used to pay such expenses. If the expenses were paid from funds of the deceased
beneficiary's estate, the claim should be filed by the executor or administrator of the estate. If the expenses have not been paid, the
claim may be filed by the person who is responsible for the payment of these expenses. However, all unpaid creditors must sign Part
IV, Reimbursement Waiver.
E. What are the time limits to apply for accrued benefits?
A claim for accrued benefits must be filed within one year from the date of death of the deceased beneficiary.
Exception: A claim for lump sum accrued benefits (benefits that were withheld from a competent veteran during hospital treatment,
institutional, or domiciliary care) must be filed within five years from the veteran's date of death. However, if the person who is
entitled to the lump sum accrued benefits has been declared incompetent by a court of law or Federal or State government agency at
the time of the veteran's death, the five year period begins from the date of termination or removal of the finding of incompetency.
F. What evidence should I submit?
1. Furnish a copy of the death certificate unless the beneficiary died in a VA medical facility.
2. If an executor or administrator of the beneficiary's estate has been assigned, submit a certified copy of the letters of administration
or letters testamentary bearing the signature and seal of the appointing court.
3. If you are claiming reimbursement for last illness and burial expenses of a beneficiary, submit all bills and statements of account
covering the services and supplies that were provided in connection with these expenses. The bill or statement of account should be
submitted on the regular billhead of the creditor and show:
the dates, nature, and costs of services or supplies provided,
the name of the deceased for whom the expenses were incurred, and
whether the expense has been paid, and, if so, by whom.
G. 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 23, "Remarks, " or attach a separate
sheet, indicating the item number to which the answers apply. Write the veteran's name and VA file number on all attachments. Make
sure you sign and date this application (Items 20a and 20b.)
H. 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.
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the
place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your
claim (or a later date when you became eligible for benefits.) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes
marriages is available at http://www.va.gov/opa/marriage/.
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 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, 58VA21/22/28,
Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, and 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. You are required to
provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized
under the Privacy Act, and, specifically may disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine eligibility for payment of accrued benefits under 38 U.S.C. 5121.
Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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 http: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 21P-601, XXXX

OMB Approved No. 2900-0216
Respondent Burden: 30 minutes
Expiration Date: XXXXX
VA DATE STAMP
(Do not write in this space)

Application for Accrued Amounts Due a Deceased Beneficiary
Please read the attached "Instructions" before you fill out this form.

SECTION I
Tell us about you
and the deceased
beneficiary

1. What is the veteran's name?
First

Middle

2. What is the veteran's Social Security Number?

Last
3. What is the VA file number?

4. What is the name of the deceased beneficiary? (If other than veteran)
First
Middle
5. What is the date of death of the beneficiary?
mo day

Last

yr

6. What is your name?
First
Middle
7. What is your Social Security Number?

Last
8. What is your date of birth?
mo day

9. What is your address?

yr

Street address, Rural Route, or P.O. Box

Apt. number

State
ZIP Code
City
10. What are your telephone numbers? (Include Area Code)

Country

Daytime
Evening
11. What is your relationship to the deceased beneficiary?

SECTION II

Tell us about the
deceased
beneficiary's
surviving relatives

12. Who are the deceased beneficiary's surviving relatives? (Check all that apply)
Child or Children (See instructions for definition of a Child.)

Spouse
None

Parent

(If "NONE," Skip to Question 13.)

If any boxes are checked in Item 12, list each person separately in Item 12a through 12d.

Relatives Surviving Beneficiary at time of death
12a. Name
(First, Middle Initial, Last)

12b. Relationship to
Beneficiary

12c. Date of Birth 12d. Complete Mailing Address
(mm/dd/yyyy)

13. Would you like to waive substitution? (If "Yes," see Paragraph C of the Instructions.)
VA FORM
XXXX

21P-601

SUPERSEDES VA FORM 21-601, SEP 2015,
WHICH WILL NOT BE USED.

Yes

No
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SECTION III

Read Paragraphs C and D of the Instructions before completing Section III. Complete this section only
if you are claiming accrued benefits for reimbursement of expenses for last illness or burial. Skip to
Section V if you are claiming accrued benefits based on your relationship to the deceased beneficiary.

Tell us about the
debts and expenses
of the last sickness
and burial of the
deceased
beneficiary

14. List the expenses of last sickness and burial in Items 14a through 14e.
14a. Name of Person or Firm

14b. Nature of Expense 14c. Amount
(For example, physician,
hospital, burial expenses,
etc.)

14d. Check One 14e. If Paid, Name of Person
or Estate Whose Funds Were
Used
Paid Unpaid

$

$

$

$

15. Have you been reimbursed from any source
for any of the expenses paid from your
personal funds?
Yes

No (If "YES," specify the amount
and source)

16. Did the beneficiary leave any other debts?

Yes

No (If "YES," go to Item 15.

If "NO," skip to Item 16.)

17. List the other debts in Items 17a and 17b.
17a. Nature of Debt

17b. Amount
$
$
$
$

18. Has or will the beneficiary's estate be legally administered?
Yes

VA FORM 21P-601, XXXX

No

(If "YES," attach a copy of the letters of administration or letters
testamentary bearing the signature and seal of the appointing
court)

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SECTION IV
Give us a waiver of
reimbursement
from all unpaid
creditors

Note: If any of the expenses listed in Item 14d are unpaid, Section IV must be completed and signed by all
unpaid creditors. If you are a creditor who is claiming accrued benefits as reimbursement, Section IV must
be completed by all other creditors and persons who provided services to the deceased beneficiary related to
last illness or burial and hold the creditor responsible for payment of their claims. If you need additional
space, please attach a separate sheet of paper providing the certification and information requested below.
I CERTIFY THAT the expense listed in Section III, Item 14d which was incurred by the claimant named in
Item 6 in connection with the last sickness and burial of the beneficiary, is due and unpaid. I further certify
that I hold the claimant responsible for the payment of any portion of the accrued benefit to which I may be
entitled in the case of the beneficiary named in Item 1 or 4 and waive my right to any such benefit. This
statement is true and correct to the best of my belief.
19a. Name of Unpaid Creditor or Firm No. 1
19b. Address of Creditor or Firm

19c. Signature of Creditor or Person
Signing for Firm

19d. Title

19e. Date Signed

mo day

yr

20a. Name of Unpaid Creditor or Firm No. 2
20b. Address of Creditor or Firm

20c. Signature of Creditor or Person
Signing for Firm

20d. Title

20e. Date Signed

mo day

yr

21a. Name of Unpaid Creditor or Firm No. 3
21b. Address of Creditor or Firm

21c. Signature of Creditor or Person
Signing for Firm

21d. Title

21e. Date Signed

mo day

yr

SECTION V

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

Give us your
Signature

22a. Signature of claimant

If you sign with an "X,"
then you must have two
people you know witness
you as you sign. They
must then sign the form
and print their names and
addresses also.

VA FORM 21P-601, XXXX

22b. Today's date
mo day yr

23a. Signature of witness (If claimant
signed above using an "X")

23b. Printed name and address of witness

24a. Signature of witness (If claimant
signed above using an "X")

24b. Printed name and address of witness

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SECTION VI

25. Remarks (If you need more space to answer a question or have a comment about a specific item
number on this form, please identify your answer or statement by the Section and item number)

Remarks - Use this
space for any
additional
statements
that you would like
to make concerning
your application.

IMPORTANT
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 which you
are not entitled to.

VA FORM 21P-601, XXXX

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