Form 21-0538 STATUS OF DEPENDENTS QUESTIONNAIRE

In Reply Refer To:

The compensation you receive for your service-connected disability includes an additional amount for your spouse and/or
child(ren). You are responsible for reporting any change in the number of your dependents.
To show continued entitlement to this additional amount, you must complete and return the form starting on page 2 of this
letter. You can also provide the information by calling the VA, at 1-800-827-1000. If you use a Telecommunications
Device for the Deaf (TDD), the federal number is 711. If the number of your dependents has not changed, we will
continue your benefits at their present rate. If the number of your dependents has changed due to either the loss or
addition of a dependent, we will adjust your payments accordingly.
If you do not notify us of the status of your dependents within 60 days from the date of this letter, we will reduce your
award by the amount of benefits you are receiving for your dependents.
VA now uses a centralized mail system. If you choose to respond in writing, please put your full name and VA file
number on each page. Send your application and any evidence in support of your claim to the following address:
Department of Veterans Affairs
Evidence Intake Center
P. O. Box 4444
Janesville, WI 53547-4444
If you are unable to mail your application or evidence, please use the following Fax Lines:
•
•

(844) 531-7818 (Toll Free)
(248) 524-4260 (Utilized for Foreign Claimants)

You have the right at any time to submit additional information or to have a personal hearing to explain or clarify your
statements. You also have the right to be represented at the hearing by an authorized veteran's service organization.
Veterans Service Center Manager
Enclosure

VA FORM
XXXX

21-0538

Page 1

OMB Approved No. 2900-0500
Respondent Burden: 10 Minutes
Expiration Date: XXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

MANDATORY STATUS OF DEPENDENTS
INSTRUCTIONS: Print all answers clearly. You must sign and date this form (Items
13 and 14). When you have completed this form, mail it to the address in the letter on
Page 1, or fax it, or take it to your local VA regional office.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH

3. VA FILE NUMBER (If applicable)

Month

Day

Year

5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

6A. PRIMARY TELEPHONE NUMBER (Include Area Code)

7. VETERAN'S SERVICE NUMBER (If applicable)

6B. SECONDARY TELEPHONE NUMBER (Include Area Code)

8. PREFERRED E-MAIL ADDRESS (Optional)

SECTION II: SPOUSE INFORMATION
9A. ARE YOU MARRIED?
YES (If "YES," complete Items 9B-9F)

9B. DATE OF MARRIAGE
Month
Day

Year

9C. CITY AND STATE, COUNTY AND STATE, or CITY AND
COUNTRY OF MARRIAGE

NO
9D. SPOUSE NAME (First, Middle Initial, Last)

9E. SPOUSE SOCIAL SECURITY NUMBER

9F. SPOUSE DATE OF BIRTH
Month

Day

Year

SECTION III: CHILD(REN) INFORMATION
NOTE - Please provide the following information for each child under age 18, over age 18 and under 23 and attending school, or of any age if permanently disabled. If you have more than four
children, list the others in Item 12, "Remarks," giving the information requested in Items 10A through 10F. If you have no children in any of the categories described above, write "None" in
Item 10A.
10A. FULL NAME OF
EACH CHILD

10B. DATE OF
BIRTH

(MM/DD/YYYY)

10C. PLACE OF
BIRTH

(City & state,County &
State, or City & Country)

10D. SOCIAL
SECURITY
NUMBER

10E. CHILD'S
RELATIONSHIP
STATUS

10F. NAME AND ADDRESS OF
PERSON HAVING CUSTODY
OF THE CHILD

(If child is not living with you)

BIOLOGICAL
STEPCHILD
ADOPTED
BIOLOGICAL
STEPCHILD
ADOPTED
BIOLOGICAL
STEPCHILD
ADOPTED
BIOLOGICAL
STEPCHILD
ADOPTED
VA FORM 21-0538, XXXX

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VETERAN'S SOCIAL SECURITY NO.

SECTION III: CHILD(REN) INFORMATION (Continued)

NOTE: Furnish the following information for each terminated dependent.
11A. FULL NAME OF EACH DEPENDENT

11B. PROVIDE REASON FOR TERMINATION

(Death, Divorce, Age)

11C. DATE OF TERMINATION

12. REMARKS

SECTION IV: VETERAN SIGNATURE
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
13. SIGNATURE OF VETERAN OR GUARDIAN

14. DATE SIGNED (MM/DD/YYYY)

SIGN HERE
IN INK

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.
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 ore 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, Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. You must give us your and your dependents SSN account information. Applicants are
required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 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 continued eligibility for an additional allowance for your spouse and/or child(ren). 38 U.S.C. 1115, Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 10 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. Valid OMB control numbers can be located on the OMB Internet page at
www.reginfo.gov/public/do/PRAMain If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-0538, XXXX

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