Form VA Form 21P-8924 VA Form 21P-8924 Application of Surviving Spouse or Child for REPS Benefi

OMB Approved No. 2900-0390
Respondent Burden: 20 minutes
Expiration Date: XX/XX/XXXX

APPLICATION OF SURVIVING SPOUSE OR CHILD FOR REPS BENEFITS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)

PRIVACY ACT INFORMATION: 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) as 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. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101(c)
(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect
prior to January 1, 1975, and still in effect. 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.
RESPONDENT BURDEN: We need this information to determine eligibility for REPS benefits (38 U.S.C. 5101 (a)). 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 INFORMATION
WHO IS ELIGIBLE: Benefits are payable to certain survivors of members or former members of the Armed Forces who died while
on active duty prior to August 13, 1981, or who died from a disability incurred in or aggravated by active duty prior to August 13,
1981. Service in the Public Health Service or National Oceanic and Atmospheric Administration does not qualify.
SURVIVING SPOUSE: If you were married to the veteran at the time of his or her death and are not currently married, you may be
eligible for REPS benefits for yourself when the youngest child in your care reaches age 16. These benefits will terminate when the
child reaches age 18, whether or not the child is still in high school.
CHILD: If you are an unmarried child of the veteran between the ages of 18 and 21 and are attending a postsecondary school full
time, you may be eligible for REPS. In the United States, "postsecondary school" refers to school above the level of high school. If
you are age 18 and still in high school, you are not eligible for REPS. However, you may apply to the Social Security Administration
for an extension of benefits.
INSTRUCTIONS
If you are applying as a surviving spouse whose youngest child in care is age 16 or 17, please complete Part II-Claimant Information.
All other questions on the form pertain to you and not to your child. If you are the veteran's child, age 18 to 21 and attending college
or other postsecondary school full time, please complete Part II-Claimant Information. All other questions on this form pertain to you.
NOTE: This form is intended to serve as an application for only one person. Additional forms can be obtained from your nearest VA
regional office.
NOTE: Action on your claim may be delayed if you do not provide all of the information requested. You are required to estimate
wage information in Part III, even if you do not know the exact wage amount(s). If you need additional space, use Item 22,
"REMARKS", or attach a separate sheet and label your answers to correspond to the question numbers on the form. Please include
the veteran's full name and VA file number on each sheet. Please type or print in ink.
The form should be returned to VA by toll-free fax at 844-531-7818 or by mail to:
VA Regional Office,
400 S. 18th St.,
St. Louis, MO 63103-2271
PART I - VETERAN'S INFORMATION

1. FIRST-MIDDLE-LAST NAME

2. SOCIAL SECURITY NUMBER

XC-

5. DATE OF DEATH

4. BRANCH OF SERVICE

ARMY

NAVY

AIR FORCE

MARINES

COAST GUARD

PART II - CLAIMANT'S INFORMATION

6. FIRST - MIDDLE - LAST NAME OF CLAIMANT (SEE INSTRUCTIONS)

7. DATE OF BIRTH (MM,DD,YYYY)

8. SOCIAL SECURITY NUMBER

10. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

9. RELATIONSHIP TO VETERAN

11. TELEPHONE NUMBER
(Include Area Code)

3. VA FILE NUMBER

12. MARITAL STATUS

13. DATE YOU MARRIED

14. DATE OF TERMINATION

Single
Married

VA FORM
XXX XXXX

21P-8924

Divorced/Widowed (If "Divorced/Widowed," complete Items 13 & 14)
SUPERSEDES VA FORM 21-8924, APR 2014,
WHICH WILL NOT BE USED.

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PART III - CLAIMANT'S EMPLOYMENT AND WAGE INFORMATION

(To be completed in full, only if you are a surviving spouse, and the youngest child in your care has reached age 16, but is not yet 18)
15. EMPLOYMENT STATUS (PLEASE SELECT ONE)

16. TOTAL EARNINGS FROM EMPLOYMENT FOR LAST CALENDAR YEAR

EMPLOYED
NOT EMPLOYED

$

SELF-EMPLOYED (Number of hours worked per month)
17. MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR THIS
CALENDAR YEAR? (You must make an estimate)

$

(Year)

18 MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR NEXT
CALENDAR YEAR? (You must make an estimate)

$

(Year)

(Year)

PART IV - REMARKS
19. REMARKS (If any)

PART V - CERTIFICATION AND SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN
IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGES IN THE INFORMATION PROVIDED ON THIS APPLICATION. To
report any changes, please contact the VA National Call Center via telephone at 1-800-827-1000.

I CERTIFY THAT the statements provided are true and correct to the best of my knowledge.
20. SIGNATURE OF CLAIMANT, CUSTODIAN, OR GUARDIAN (Sign in ink)

21. DAYTIME PHONE NUMBER (Include Area Code)

22. 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 for the fraudulent acceptance of any payment to which you are not
entitled.
PART VI - CERTIFICATION OF SERVICE-CONNECTION OR DEATH ON ACTIVE DUTY
I HEREBY CERTIFY THAT the deceased died on active duty prior to August 13, 1981, or died from a service-connected disability incurred or aggravated prior to August 13,1981.
23A. SIGNATURE AND TITLE OF VA OFFICIAL

VA FORM 21P-8924, XXX XXXX

23B. VARO (City) AND STATION NUMBER

23C. DATE SIGNED

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