Form 21-686c Application Request to Add and/or Remove Dependents

NOTICE TO VETERAN/CLAIMANT REGARDING THE INFORMATION AND EVIDENCE NEEDED TO
SUPPORT A CLAIM FOR ADDITIONAL BENEFITS FOR A DEPENDENT OR TO REMOVE A
DEPENDENT FROM AN AWARD
Use this form and the attached application to:

• submit a claim for additional benefits for a dependent, or
• request removal of a dependent from your award.
The table below identifies the types of dependents for whom VA beneficiaries may be entitled to additional benefits.
If you are a …

Then you may be entitled to additional benefits for …

veteran entitled to disability compensation who has a
combined disability rating of at least 30 percent

•
•
•
•
•

a spouse,
children under age 18,
children that are between the ages of 18 and 23 who are attending school,
children over age 18 that are permanently incapable of self-support, and/or
dependent parents.

veteran entitled to Veterans Pension

•
•
•
•

a spouse,
children under age 18,
children that are between the ages of 18 and 23 who are attending school, and/or
children over age 18 that are permanently incapable of self-support

surviving spouse entitled to survivors benefits

• children under age 18,
• children that are between the ages of 18 and 23 who are attending school, and/or
• children over age 18 that are permanently incapable of self-support.
Exception: A surviving spouse entitled to Dependency and Indemnity Compensation (DIC) is
not entitled to additional benefits for children over age 18 that receive DIC in their own right.

TABLE OF CONTENTS
The table below provides a guide to the instructions and the application. Certain sections of this application are required. Be aware that
you must complete Section I - Veteran/Claimant's Identification Information and Section X - Veteran/Claimant's Certification
and Signature. If these sections are not complete, we will not be able to process your claim for dependents. Otherwise, complete the
remaining sections that apply to you.
If you are claiming/reporting …
Instructions
Application
Add a Spouse

Pages 3 and 4

Pages 7 and 8

Add a Child

Pages 4 - 5

Pages 8 and 9

Reporting Divorce

Page 5

Page 10

Reporting on Stepchildren
• Add
• Remove

Page 4
Page 6

Pages 8 and 9
Page 10
Page 10

Reporting Marriage of a Dependent Child

Page 5
Page 6
Page 6
Page 6

Reporting a Schoolchild over 18 has Stopped Attending School

Page 6

Page 11

Reporting Death of a Dependent
• Spouse
• Child
• Dependent Parent

Additional Children

Page 10

Addendum - Page 12

CIRCUMSTANCES THAT REQUIRE ADDITIONAL FORMS
Under certain circumstances, other forms in addition to VA Form 21-686c, Request to Add and/or Remove Dependents, must be
provided when claiming additional benefits for a dependent. The table below describes those circumstances. All VA forms are
available at www.va.gov/vaforms.
Page 1
VA FORM 21-686c, XXX XXXX

If ...

Then submit ...

you are seeking additional benefits for a child or children
who are between the ages of 18 and 23 who are attending
school

VA Form 21-674, Request for Approval of School Attendance.

• you are entitled to Veterans Pension (instead of
disability compensation based on serviceconnected disabilities), and
• you are seeking additional benefits for a spouse
only

Note: Submit VA Form 21-686c in addition to VA Form 21-674 only if you
have never received additional benefits for the child or children.
submit VA Form 21P-0516-1, Improved Pension Eligibility Verification
Report (Veteran With No Children), in addition to VA Form 21-686c.

• you are entitled to Veterans Pension
• you are seeking additional benefits for a child or
children (with or without a spouse), and
• the child or children are under the age of 23 or
permanently incapable of self-support

VA Form 21P-0517-1, Improved Pension Eligibility Verification Report
(Veteran With Children), in addition to VA Form 21-686c.

• you are entitled to Survivors Pension, (instead of
DIC based on a Veteran's service-connected
death) and
• you are seeking additional benefits for a child or
children that are either under the age of 23 or
incapable of self-support.

VA Form 21P-0519s-1, Improved Pension Eligibility Verification Report
(Surviving Spouse With Children), in addition to VA Form 21-686c.

• you are a Veteran entitled to disability
compensation (based on service-connected
disabilities), and
• you are seeking additional benefits for a
dependent parent or parents, or
• you are seeking to remove your dependent parent
for any change in his/her marital status and/or
significant change in a parent's income or net
worth.

VA Form 21P-509, Statement of Dependency of Parent(s).

• you are a Veteran entitled to disability
compensation, and
• you are seeking additional benefits for a spouse
who requires aid and attendance

Note: There is no need to submit VA Form 21-686c when filing a claim for
additional benefits for a dependent parent or parents.

• VA Form 21-2680, Examination for Housebound Status or
Permanent Need for Regular Aid and Attendance, or (if your spouse
resides in a nursing home)
• VA Form 21-0779, Request for Nursing Home Information in
Connection with Claim for Aid and Attendance.
Note: Submit VA Form 21-686c in addition to one of the forms referenced
above only if you have never received additional benefits for your spouse.

if you are a Veteran seeking additional benefits for a
spouse based on a common-law marriage

submit the following forms in addition to VA Form 21-686c:
• VA Form 21-4170, Statement of Marital Relationship, and
• VA Form 21P-4171, Supporting Statement Regarding Marriage

HOW TO SUBMIT
May I apply electronically? You may apply for additional benefits for dependents and/or request removal of dependents online
through eBenefits at www.ebenefits.va.gov. If you do not have an account you must create one once you've logged into your
account, select the "Add or Remove Dependent" hyperlink on the "Apply for Benefits" page. Once you have electronically submitted
your claim form, you will be able to track the status of your claim using eBenefits.
NOTE: You may wish to contact an accredited veteran service officer (VSO) to assist you with your application. You can locate a list of
vso's at https://www.va.gov/vso/ .
WHERE TO SEND INFORMATION AND EVIDENCE
MAIL TO:

FAX TO:

ONLINE:

Department of Veterans Affairs
Evidence Intake Center
PO Box 4444 Janesville, WI 5347-4444

844-531-7818 (Toll Free)
248-524-4260 (Foreign Claims)

www.ebenefits.gov

VA FORM 21-686c, XXX XXXX

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IMPORTANT: Supplying your Social Security Number (SSN) is mandatory. Applicants are required to provide their SSN, unless
a SSN has not been assigned. Use Section IX, Item 25, Remarks, to explain why a SSN has not been assigned.
TO ADD A SPOUSE TO A VETERAN'S AWARD:
Marriage by Ceremony
VA will require additional evidence* to establish a dependent spouse, if
• you do not reside within a state (for example: territories and possession of the United States),
• your entries on the application conflict with other information provided,
• information of record questions the validity of the marriage, or
• there is an indication of fraud or misrepresentation that cannot be resolved through contact with the claimant or a review of the
information of record.
*Additional evidence refers to the following
Primary evidence of a marriage consists of a copy or abstract of the public record of a marriage, or a copy of the church record of
marriage, containing sufficient data to identify the
• parties involved,
• date (month, day, and year) and place (city and state, county and state, or city and country) of the marriage, and
• number of prior marriages for each spouse, if not shown on the official record.
If primary evidence of marriage is unavailable, a marriage may still be established by submission of the following evidence in the order of
preference shown below:
• an official report from the veteran's service department regarding a marriage that occurred while the veteran was in service,
• an affidavit of the clergyman or magistrate who officiated in the marriage ceremony,
• the original certificate of marriage, if it is deemed genuine and free from alteration,
• affidavits or certified statements signed by two or more witnesses that attended the marriage ceremony, or
• any other secondary evidence that reasonably supports the belief that a valid marriage occurred.
Note: The process to establish a same-sex or transgender marriage is no different than the process to establish a marriage between persons
of the opposite sex.
Establishing a Common-Law Marriage
In some states it is possible to contract a marriage without a ceremony and without registration of the marriage. This type of marriage is
referred to as a common-law marriage.
VA may recognize a common-law marriage that was considered valid in the state in which it took place. A common law marriage
generally requires an agreement between the parties to be married, cohabitation, and holding themselves out to the public as married.
Evidence that must be submitted to claim a common-law marriage:
• VA Form 21-4170 completed by the veteran.
• VA Form 21-4170 completed by the veteran's spouse in the common-law marriage.
• Two completed VA Forms 21P-4171, each form completed by two different persons that can provide their personal observations
about the parties to the common-law marriage and the relationship that exists/existed between them.
• Copies of any birth certificates from children born of the common-law marriage.
Tribal Ceremony
VA may recognize marriages performed in accordance with tribal custom.
To establish a tribal marriage, a claimant must provide all of the following:
• Affidavits from the parties married by tribal custom that include the name of the tribe, date (month, day, and year) of marriage,
place (city and state, county and state, or city and country) where the marriage ceremony occurred, and name/mailing address of
the person who performed the ceremony.
• Affidavits from at least two people who were present at the time the tribal marriage ceremony took place. The affidavits must
include the name of the tribe, date (month, day, and year) of marriage, place (city and state, county and state, or city and country)
where the marriage ceremony occurred, and name/mailing address of the person who performed the ceremony.
• Affidavit from the person who performed the ceremony, showing the date (month, day, and year) and place (city and state,
county and state, or city and country) where the marriage ceremony occurred, and that person's authority for conducting the
ceremony.
VA FORM 21-686c, XXX XXXX

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Proxy Marriage
A proxy marriage is a wedding in which one or both of the individuals being united are not physically present, and are instead
represented by other persons. If both partners are absent a double proxy wedding occurs.
Marriage by proxy typically happens when a couple wish to marry but one or both partners cannot attend for reasons such as military
service, imprisonment, or travel restrictions; or when a couple lives in a jurisdiction in which they cannot legally marry.
All documents/certificates issued in connection with a claimed proxy marriage must be provided to establish a proxy marriage for VA
purposes.
Note: The validity of a proxy marriage is dependent upon the law in effect at the location in which the proxy marriage was performed.
Spousal Aid & Attendance (A&A)
VA may pay additional benefits to a Veteran for a spouse with severe medical need/disability (ies). To claim the additional benefits, a
Veteran must complete a VA Form 21-2680 and submit medical evidence showing his or her spouse
• is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes or concentric contraction of the visual
field to 5 degrees or less; or
• is a patient in a nursing home because of mental or physical incapacity (by completing VA Form 21-0779); or
• requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding,
dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her
daily environment.
TO ADD A CHILD TO A VETERAN/CLAIMANT'S AWARD:
Unmarried Child
A person must be unmarried in order to be considered a child for VA purposes.
VA may continue paying additional benefits for an unmarried child
• until the child reaches age
o 18, or
o 23, if the child is attending an approved school,
• or indefinitely if the child becomes permanently incapable of self-support before his/her 18th birthday.
VA will require a copy of the child's birth certificate, if
• you do not reside within a state (example: territories and possession of the United States),
• your entries on the application conflict with other information provided, or
• there is an indication of fraud or misrepresentation that cannot be resolved through contact with the claimant or a review of the
information of record.
School-Age Child
You must complete and submit VA Form 21-674 to claim additional benefits for a child who is
• between the ages of 18 and 23, and
• attending school.
Notes:
• Claimants with more than one school-age child must complete a separate VA Form 21-674 for each child.
• VA Form 21-674 is used to report
o school attendance,
o a change in the educational facility a child is attending, and/or
o a change to a child's graduation date.
Stepchild
VA will require additional evidence* to add a stepchild, if
• you do not reside within a state (example: territories and possession of the United States),
• your entries on the application conflict with other information provided,
VA FORM 21-686c, XXX XXXX

Page 4

• information of record raises questions the validity of the stepchild's biological or adoptive parent's marriage to the veteran,
or
• there is an indication of fraud or misrepresentation that cannot be resolved through contact with the claimant or a review of the
information of record.
*Additional evidence, includes
Information or evidence VA might require to process a claim for additional benefits for a veteran's stepchild include the following:
• date (month, day, and year) the veteran married the stepchild's biological or adoptive parent,
• a copy of the stepchild's
• birth certificate, showing the names of both parents,
• decree of adoption, and/or
• adoptive placement agreement,
• statement that the stepchild became a member of the veteran's household before reaching age 18, or between the ages of 18
and 23 while enrolled in or attending school,
• statement from the veteran indicating whether he/she is providing at least one half of the stepchild's total financial support,
and
• (if the stepchild does not reside in the Veteran's household) the full mailing address of the stepchild and a detailed explanation
as to the reason the stepchild does not reside in the veteran's household.
Note: VA considers a stepchild to be a member of a veteran's household if he/she lives apart from the veteran for any of the following:
• medical reasons,
• attend school,
• fulfill a military service obligation,
• was a member of the veteran's house at the time of the veteran's death,
• was (at the time of the veteran's death) in the veteran's "constructive custody," and the stepchild was received at least half of
his/her support from the veteran, or
• was, at the time of the veteran's death, in a veteran's "constructive custody," and lived apart from the veteran at the time of
death because the stepchild had medical reasons, was attending school, or was fulfilling a military obligation.
Adopted Child
A claim for additional benefits for an adopted child must include a copy of the
• final decree of adoption,
• adoptive placement agreement,
• interlocutory decree of adoptions, or
• revised birth certificate.
Note: VA cannot pay additional benefits for a grandchild or foster child unless the claimant submits evidence (referenced above)
showing the veteran adopted the grand/foster child.
Child Incapable of Self-Support
VA may pay additional benefits for a child beyond his/her 23rd birthday if VA determines the child became permanently incapable of
self-support before his/her 18th birthday.
A claim for additional benefits for a child who is incapable of self-support must include
• medical evidence showing a permanent mental or physical disability existed before his/her 18th birthday, and
• a statement from an attending physician showing the nature and extent of the child's physical or mental impairment.
REMOVAL OF A SPOUSE FROM A VETERAN/CLAIMANT'S AWARD:
Divorce or Death of a Spouse
VA must remove a spouse from a Veteran's award when the spouse dies or divorces/annuls the marriage to the veteran.
In order to ensure VA uses the most beneficial effective date for removing a spouse from a Veteran's award, the Veteran must
• identify the event (death, divorce, annulment) that warrants removal of the spouse, and
• provide the date (month, day, and year) of that event.
Notes:
• A spouse (who is estranged, separated, or living separately from the veteran) is still considered a dependent spouse for VA
compensation purposes.
• After the veteran divorces from the stepchild's parent, continued stepchild benefits may be paid if the veteran provides at least
half of the stepchild's support.
VA FORM 21-686c, XXX XXXX

Page 5

REMOVAL OF A CHILD FROM A VETERAN/CLAIMANT'S AWARD:
Married Child
A person must be unmarried to qualify as a child for VA purposes. Therefore, a person of any age who marries ceases to be a child for
VA purposes.
In order to ensure VA uses the most beneficial effective date for removing a married child from a veteran/claimant's award, the veteran/
claimant's must provide the date (month, day, and year) of the child's marriage.
Note: If a child marries, and then the marriage is terminated by annulment or declared void, VA may resume the payment of additional
benefits for the child.
Child Who Is Between the Ages of 18 and 23 and Not Attending School
To be considered a school child for VA purposes a person must be between the ages of 18 and 23 and attending a VA-accredited
educational facility.
In order to ensure VA uses the most beneficial effective date for removing a child from a veteran/claimant's award because the child is
between the ages of 18 and 23 and no longer attending school, the veteran/claimant must provide the date (month, day, and year) the
child last attended school.
Note: VA cannot pay additional benefits for a school child when the school child is receiving survivors benefits in his/her own right or
Dependents Educational Assistance (38 U.S.C. Chapter 35).
Stepchild
VA will use the most beneficial effective date when removing a stepchild from the veteran's award. The date (month, day, and year) that
the stepchild left the veteran's household and the date (month, day, and year) the veteran stopped providing support for the stepchild.
Note: The awarding of legal custody of a stepchild to someone other than the veteran/claimant will not affect the additional benefits to
which the veteran/claimant is entitled for that child, as long as the stepchild remains a member of the veteran/claimant's household.
Child Given Up for Adoption
A veteran/claimant who gives up a child for adoption is no longer entitled to additional benefits for that child.
VA will use the most beneficial effective date when removing the veteran's child that has been given up for adoption. The date (month,
day, and year) that the child was given up for adoption must be provided.
Death of a Child
VA will use the most beneficial effective date when a dependent child dies and must be removed from the veteran/claimant's award. The
date (month, day, and year) of the child's death must be provided.
REMOVAL OF A DEPENDENT PARENT DUE TO DEATH:
Dependent Parent
VA will use the most beneficial effective date when a dependent parent dies and must be removed from the veteran/claimant's award.
The date (month, day, and year) of the parent's death must be provided.

For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.

VA FORM 21-686c, XXX XXXX

Page 6

OMB Approved No. 2900-0043
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)

APPLICATION REQUEST TO ADD AND/OR
REMOVE DEPENDENTS
INSTRUCTIONS: Make sure you sign and date this form in Items 26A and 26B.
Note: Unless the claimant is the veteran's surviving spouse or a designated "alternate
signer", the veteran must sign in Item 26A. When you have completed this form, you
can mail or fax the form to the address or the fax number shown at the bottom of page
2 or you may complete and submit the form online at www.ebenefits.gov.
SECTION I: VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION
(Note: This section is MANDATORY and completion is required to process your claim, any omission may delay claim processing time)
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER

2. SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

5. CLAIMANT'S NAME (If other than veteran) (First, Middle Initial, Last)

6. CLAIMANT'S SOCIAL SECURITY NUMBER

7. VETERAN'S SERVICE NUMBER (If applicable)

8. TELEPHONE NUMBER (Include Area Codel)

9. E-MAIL ADDRESS (Optional)

10. COMPLETE MAILING ADDRESS OF VETERAN/CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

SECTION II: INFORMATION NEEDED TO ADD SPOUSE
11A. SPOUSE'S NAME (First, Middle Initial, Last)

11C. SPOUSE'S SOCIAL SECURITY NUMBER (SSN) (If
your spouse does not have an SSN, explain why in Section
IX, Item 25, Remarks)

11B. SPOUSE'S DATE OF BIRTH (MM/DD/YYYY)
Day

Month

Year

11E. PLACE OF MARRIAGE (City and State, County and
State, or City and Country)

11D. DATE OF MARRIAGE (MM/DD/YYYY)
Month

Day

Year

11F. HOW WERE YOU MARRIED? (Check one)
RELIGIOUS CEREMONY (i.e. Minister, Priest, Rabbi, etc.) or CIVIL CEREMONY (i.e. Justice of the Peace)
COMMON LAW

TRIBAL

PROXY

OTHER (Explain)
12B. SPOUSE'S VA FILE NUMBER

12A. IS YOUR SPOUSE ALSO A VETERAN?

12C. SPOUSE'S SERVICE NUMBER (If applicable)

YES (If "YES," complete Items 12B and 12C)
NO
13A. DO YOU LIVE TOGETHER?

13B. REASON FOR SEPARATION (For example, marital problems, job requirements, health, etc.)

YES
NO (If "NO," complete Items 13B and 13C)
13C. PRESENT MAILING ADDRESS OF SPOUSE (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province
VA FORM
XXX XXXX

21-686c

Country

ZIP Code/Postal Code
SUPERSEDES VA FORM 21-686c, JUN 2017,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NO.

NOTE: You must provide complete information about your prior marriages and your current spouse's prior marriages.
VETERAN/CLAIMANT'S PREVIOUS MARITAL INFORMATION
(If no prior marriages, this section may be left blank)
14A. DATE AND PLACE
OF MARRIAGE
CITY & STATE,
COUNTY & STATE, or
CITY & COUNTY

MM/DD/YYYY

14B. TO WHOM MARRIED
(First, middle, last name)

14D. DATE AND PLACE MARRIAGE
TERMINATED

14C. REASON FOR
TERMINATION
(Death, Divorce,
Annulment)

MM/DD/YYYY

CITY & STATE
COUNTY & STATE, or
CITY & COUNTY

CURRENT SPOUSE'S PREVIOUS MARITAL INFORMATION
(If no prior marriages, this section may be left blank)
15A. DATE AND PLACE
OF MARRIAGE
CITY & STATE
COUNTY & STATE, or
CITY & COUNTY

MM/DD/YYYY

15B. TO WHOM MARRIED
(First, Middle, Last Name)

15C. REASON FOR
TERMINATION
(Death, Divorce,
Annulment)

15D. DATE AND PLACE MARRIAGE
TERMINATED
MM/DD/YYYY

CITY & STATE
COUNTY & STATE, or
CITY & COUNTY

SECTION III: INFORMATION NEEDED TO ADD CHILD(REN)
(If claiming more than four children, fill out addendum (Page 12) and submit with application)
16A. NAME OF FIRST CHILD TO ADD (First, Middle Initial, Last)

16B. SOCIAL SECURITY NUMBER

16D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

16C. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

16E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

16F. IF THE CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

16G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item16H)
16H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
OTHER (Explain)
DATE:______________________
DECLARED VOID
ANNULLED
16I. IF YOU CHECKED "STEPCHILD" IN ITEM 16G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________(MM/DD/YYYY)
NO
VA FORM 21-686c, XXX XXXX

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VETERAN'S SOCIAL SECURITY NO.

SECTION III: INFORMATION NEEDED TO ADD CHILD(REN) (Continued)
(If claiming more than four children, fill out addendum (Page 12) and submit with application)
17A. NAME OF SECOND CHILD TO ADD (First, Middle Initial, Last)

17B. SOCIAL SECURITY NUMBER

17D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

17C. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

17E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
17F. IF THE CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

17G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

ADOPTED

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 17H)
17H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

OTHER (Explain)

DECLARED VOID

17I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________(MM/DD/YYYY)
NO
18A. NAME OF THIRD CHILD TO ADD (First, Middle Initial, Last)

18B. SOCIAL SECURITY NUMBER

18D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

18C. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

18E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

18F. IF THE CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

18G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

ADOPTED

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 18H)
18H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

DECLARED VOID

OTHER (Explain)

18I. IF YOU CHECKED "STEPCHILD" IN ITEM 18G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________(MM/DD/YYYY)
NO
19A. NAME OF FOURTH CHILD TO ADD (First, Middle Initial, Last)
19B. SOCIAL SECURITY NUMBER

19D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

19C. DATE OF BIRTH (MM/DD/YYYY)
Day
Year
Month

19E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

19F. IF CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
19G. CHILD STATUS (Check all that apply)
BIOLOGICAL
STEPCHILD

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 19H)

CHILD INCAPABLE
OF SELF-SUPPORT

19H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

DECLARED VOID

OTHER (Explain)

19I. IF YOU CHECKED "STEPCHILD" IN ITEM 19G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________(MM/DD/YYYY)
NO
VA FORM 21-686c, XXX XXXX

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VETERAN'S SOCIAL SECURITY NO.

SECTION IV: VETERAN/CLAIMANT REPORTING DIVORCE FROM FORMER SPOUSE
(If you have stepchild(ren), also complete Section V)
20A. NAME OF FORMER SPOUSE (First, Middle Initial, Last)

20C. DATE OF DIVORCE (MM/DD/YYYY)

20B. PLACE OF DIVORCE (Provide city and state, county and state, or city and country)

Month

Day

Year

SECTION V: VETERAN/CLAIMANT REPORTING ON STEPCHILD(REN)
21A. DID YOU HAVE A STEPCHILD(REN) THAT WAS THE BIOLOGICAL OR ADOPTED CHILD(REN) OF THE FORMER SPOUSE LISTED IN ITEM 20A?
YES (If "YES," list the name(s) of the stepchild(ren) here):
NO (If "NO," skip to Section VI)
21B. ARE YOU STILL SUPPORTING YOUR STEPCHILD(REN) LISTED IN ITEM 21A?
YES (If "YES," complete Items 21C through 21G)
NO

If "NO," skip to Section VI)

21C. NAME OF
STEPCHILD YOU ARE
SUPPORTING

21D. IF STEPCHILD DOES NOT LIVE
WITH YOU, PROVIDE THE NAME OF
PERSON WITH WHOM
STEPCHILD RESIDES

21E. IF STEPCHILD
21F. DATE STEPCHILD
LEFT VETERAN'S
DOES NOT LIVE WITH YOU,
HOUSEHOLD
PROVIDE A COMPLETE ADDRESS

21G. FINANCIAL
SUPPORT
PROVIDED
More than half
Half
Less than half
More than half
Half
Less than half
More than half
Half
Less than half
More than half
Half
Less than half

SECTION VI: VETERAN/CLAIMANT REPORTING DEATH OF A DEPENDENT
22A. DEPENDENT TYPE (Check all that apply)
SPOUSE

MINOR CHILD (UNDER 18 YEARS OLD

CHILD INCAPABLE OF SELF-SUPPORT

22B. NAME OF DEPENDENT(S)
(First, Middle Initial, Last)

STEPCHILD

ADOPTED

DEPENDENT PARENT

18-23 YEARS OLD AND IN SCHOOL

22C. DATE OF DEATH
(MM/DD/YYYY)

22D. PLACE OF DEATH
(City & State, County & State, or City & Country)

SECTION VII: VETERAN/CLAIMANT REPORTING MARRIAGE OF DEPENDENT CHILD
23A. NAME OF CHILD (First, Middle Initial, Last)

23B. DATE OF MARRIAGE (MM/DD/YYYY)
Month

Day

VA FORM 21-686c, XXX XXXX

Year

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VETERAN'S SOCIAL SECURITY NO.

SECTION VIII: VETERAN/CLAIMANT REPORTING A SCHOOLCHILD OVER 18 HAS STOPPED ATTENDING SCHOOL
24A. NAME OF SCHOOLCHILD (First, Middle Initial, Last)

24B. DATE SCHOOLCHILD STOPPED ATTENDING SCHOOL (MM/DD/YYYY)
Day
Year
Month

SECTION IX: REMARKS
25. REMARKS (If any)

SECTION X: VETERAN/CLAIMANT'S CERTIFICATION AND SIGNATURE
(Note: This section is MANDATORY and completion is required to process your claim, any omission may delay claim processing time)

IMPORTANT: The primary purpose of this form is to gather information or statements that may result in a change to your VA benefits. By
signing this form you have given permission to make benefit payment changes that could result in the creation of an overpayment. If such
adverse actions are taken you will receive additional notification from VA regarding repayment options.
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
26A. SIGNATURE OF VETERAN/CLAIMANT OR ALTERNATE SIGNER* (Please sign in ink)

26B. DATE (MM/DD/YYYY)

*ALTERNATE SIGNER: By signing on behalf of the claimant, I certify that the claimant is:
• under the age of 18,
• mentally incompetent to provide substantially accurate information needed to complete the form or to certify that the statements made on the
form are true and complete, or
• physically unable to sign the form, and
*ALTERNATE SIGNER: By signing on behalf of the claimant, I certify that I am:
•
•
•
•

a court-appointed representative,
an attorney in fact or agent authorized to act on behalf of the claimant under a durable power of attorney,
a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative, or
a manager or principal officer acting on behalf of an institution which is responsible for the care of the claimant.

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 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 and your dependents' SSN
account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 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 marital status and eligibility for an additional allowance for dependents under 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 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 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 21-686c, XXX XXXX

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VETERAN'S SOCIAL SECURITY NO.

SECTION XI: ADDITIONAL CHILD(REN) (Addendum)
(Please submit this page with the completed application if you have additional children to add to your claim. If more space is
needed, please make additional copies of this page to submit with your application.)
1A. NAME OF CHILD TO ADD (First, Middle Initial, Last)
1B. SOCIAL SECURITY NUMBER

1C. DATE OF BIRTH (MM/DD/YYYY)
Day
Month

1D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

Year

1E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

1F. IF CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

1G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

ADOPTED

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 1H)
1H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

OTHER (Explain)

DECLARED VOID

1I. IF YOU CHECKED "STEPCHILD" IN ITEM 1G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________ (MM/DD/YYYY)
NO
2A. NAME OF CHILD TO ADD (First, Middle Initial, Last)

2B. SOCIAL SECURITY NUMBER

2C. DATE OF BIRTH (MM/DD/YYYY)
Day
Month

2D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

Year

2E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

2F. IF CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

2G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

ADOPTED

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 2H)
2H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

OTHER (Explain)

DECLARED VOID

2I. IF YOU CHECKED "STEPCHILD" IN ITEM 2G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________ (MM/DD/YYYY)
NO
3A. NAME OF CHILD TO ADD (First, Middle Initial, Last)

3B. SOCIAL SECURITY NUMBER

3C. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

3D. PLACE OF BIRTH (Provide city and state, county
and state, or city and country)

Year

3E. IF THE CHILD DOES NOT LIVE WITH VETERAN PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

3F. IF CHILD DOES NOT LIVE WITH VETERAN, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
3G. CHILD STATUS (Check all that apply)
BIOLOGICAL

STEPCHILD

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE
OF SELF-SUPPORT

CHILD PREVIOUSLY MARRIED (If checked, provide the date of marriage termination and how the marriage was terminated in Item 3H)
3H. PROVIDE DATE AND HOW MARRIAGE TERMINATED
DATE:______________________

ANNULLED

DECLARED VOID

OTHER (Explain)

3I. IF YOU CHECKED "STEPCHILD" IN ITEM 3G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES (If "Yes," provide the date the child entered veteran's household): __________________________ (MM/DD/YYYY)
NO
VA FORM 21-686c, XXX XXXX

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