Form VA Form 21P-535 VA Form 21P-535 Application for Dependency and Indemnity Compensation by

General Instructions
For Application for Dependency and Indemnity Compensation by Parent(s) (Including Accrued Benefits and
Death Compensation when Applicable)
VA Form 21P-535
Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
If you have any questions about this form, how to fill it
out, or about VA 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 1-800-8271000 (Hearing Impaired TDD line 711). You may also
contact VA by Internet at https://iris.custhelp.va.gov.
B. What is the purpose of VA Form 21P-535?
Use VA Form 21P-535 to apply for:
• VA benefits you may be entitled to receive as the
surviving parent(s) of a deceased veteran
• Any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).
If you apply for one of these benefits, the law requires that
we also consider your entitlement for the other.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security benefits by using the
SSA-24 form attached to this VA form. You don't have to
apply if you don't want to or have already done so. If you
do want to apply, fill it out and leave it attached. We will
send it to the Social Security Administration for you.
They will then contact you.
D. What is dependency and indemnity compensation
(DIC), and how does VA decide what I will or will not
receive?
DIC may be payable to parent(s) when:
• a veteran's death occurred in service, or
• a veteran dies of a service-connected disability,
AND
• your income is limited.
VA pays Parents' DIC based on the amount of the
claimant's countable income and whether the claimant is
the sole surviving parent of the veteran or one of two
parents. This is based on law. If the claimant is married
and lives with his/her spouse, the claimant's and the
spouse's income are counted. VA must include as income
payments received from all sources that Federal law
specifies.
VA FORM
XXX XXXX

21P-535

Benefit rates and income limits are frequently changed, so
it is not possible to keep this information current in these
instructions. You can find out what the current income
limitations and rates of benefits are by contacting your
nearest VA regional office. You can locate your local VA
regional at the following web site www.va.gov/directory.
Note: Unless a claim for DIC is filed within one year from
the date of the veteran's death, that benefit is not payable
from a date earlier than the date VA receives the claim.
E. How do I apply for the aid and attendance
allowance?
VA may pay a higher rate of DIC to a surviving parent who
is blind, a patient in a nursing home, or otherwise needs
regular aid and attendance. If you wish to apply for this
benefit, check "Yes" for Item 19.
F. How do I complete my application?
Print or type 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
34, "Remarks, " or attach a separate sheet, indicating the
item number to which the answers apply. Make sure you
sign and date this application (Items 30a through 31b).
Note: If the claim is being made on behalf of an
incompetent person, the application form should be
completed and filed by the legal guardian. If no legal
guardian has been appointed, it may be completed and
filed by some person acting on behalf of the incompetent
person.
G. What do I do when I have completed my application?
When you have completed this application, mail it to the
Pension Center address shown below. 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 mailing it.

SUPERSEDES VA FORM 21-535, MAY 2018,
WHICH WILL NOT BE USED.

Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365
Page 1

H. How can I assign someone to act as my
representative?
A representative can be an accredited member of an
accredited organization or other service organization that
the Secretary of Veterans Affairs recognizes, an agent
recognized by VA, or a licensed lawyer. If you appeal the
decision, agents and attorneys can charge you for services
that you receive from them only after the Board of
Veterans' Appeals (BVA) gives you its final decision
about your application. That means you can use an
attorney during any stage of your application for benefits;
however, the agent or attorney cannot charge you for
services unless you are trying to resolve a dispute with
VA after BVA has made a decision about your claim.
If you want to use a representative to help you with your
application, contact the nearest VA regional office.
Depending on the type of representative you want to
designate, we will send you one of the following forms:
VA Form 21-22, Appointment of Veterans Service
Organization as Claimant's Representative,

or VA Form 21-22a, Appointment of Individual as
Claimant's Representative.
You may also download these forms at
www.va.gov/vaforms/. If you have already designated a
representative, no further action is required on your part.
I. What if I believe that VA has made an error in
processing or deciding my benefits?
You can ask for a personal hearing at any time during the
processing of your claim. That means you can ask for the
hearing while VA is processing your claim or after VA has
made a decision. You should contact the nearest VA
regional office and tell them that you want a personal
hearing on your case. Someone in the local VA regional
office will arrange a time and a place for your hearing. At
this hearing, you may bring witnesses. VA will record
whatever you and your witnesses say during the hearing
and include it in the official record. VA will furnish the
hearing room and officials, and prepare a transcript of the
hearing. VA cannot pay your expenses or the expenses of
anyone you want to bring with you to the hearing.

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: 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 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 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. The requested
information is considered relevant and necessary to determine maximum benefits under the law. 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 eligibility for death benefits and accrued benefits under 38 U.S.C. 1121,
1310, 1315, and 5121. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of
1 hour and 12 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 21P-535, XXX XXXX

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OMB Control No. 2900-0005
Respondent Burden: 1 hour and 12 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION BY PARENT(S)
(Including Accrued Benefits and Death Compensation when Applicable)
INSTRUCTIONS: Please read the attached "General Instructions" and the Privacy Act and Respondent Burden
information before completing this form.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH
Month

Day

Year

6. VETERAN'S SERVICE NUMBER (If applicable)

5. VETERAN'S DATE OF DEATH? (Month, Day, Year)
Month

Day

Year

7. NAME OF PERSON FILING CLAIM? (First, Middle Initial, Last)

8. WHAT IS YOUR RELATIONSHIP TO THE VETERAN?

9. HAVE YOU EVER FILED A CLAIM WITH VA?

Yes

No

10. WHAT IS YOUR VA FILE NUMBER?

(If "Yes," answer Item 10)

11. EMAIL ADDRESS (If applicable)

12. TELEPHONE NUMBER (Include Area Code)

13A. DID THE VETERAN SERVE UNDER ANOTHER NAME?

13B. LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER:

Yes

No

(If "Yes," answer Item 13B)

NOTE: Attach a copy of the death certificate unless the veteran died while serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard, or
as a commissioned officer in the National Oceanic and Atmospheric Administration, Coast and Geodetic Survey, Environmental Science Services
Administration, or Public Health Service, or in a hospital or institution under the control of the U.S. government.
SECTION II: VETERAN'S ACTIVE DUTY SERVICE
NOTE: SKIP TO SECTION III IF THE VETERAN WAS RECEIVING VA COMPENSATION OR PENSION AT THE TIME OF HIS/HER
DEATH. If the veteran never filed a claim with VA, attach the original DD214 or a certified copy for each period of service listed. We will return
original documents to you.
If more space is needed use Item 34, "Remarks,".
14A. VETERAN ENTERED ACTIVE SERVICE (Month, Day, Year)

14B. PLACE ENTERED ACTIVE SERVICE

14C. SERVICE NUMBER

14D. VETERAN LEFT ACTIVE SERVICE (Month, Day, Year)

14E. PLACE LEFT ACTIVE SERVICE

14F. BRANCH OF SERVICE

14G. GRADE, RANK
OR RATING

SECTION III: VETERAN'S PARENT(S) INFORMATION

NOTE: Parent means a biological or adoptive parent, or a foster parent. A foster parent is a person who stood in the relationship of a
parent to a veteran for at least one year before the veteran's last entry into active service. The foster relationship must have begun prior
to the veteran's 21st birthday. If you are claiming benefits as the foster parent of the veteran, you will also need to complete VA Form
21P-524, Statement Of Person Claiming To Have Stood In Relation of Parent. If you need a copy of this form, you may download the
form at www.va.gov/vaforms. Note: Only one parent can be recognized for benefit payment purposes.
• The age of majority is determined by State law and is age 18 in most States. Contact your State government for more information.
• Provide a copy of the veteran's public record of birth or a copy of the court record of adoption if the veteran was adopted.
• Parental control is considered to have been given up if the parent has ceased to provide for the child and the normal parent/child
relationship has been broken.
VA FORM
XXX XXXX

21P-535

SUPERSEDES VA FORM 21-535, MAY 2018,
WHICH WILL NOT BE USED.

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Veteran's Social Security No.

SECTION III: VETERAN'S PARENT(S) INFORMATION (Continued)
15B. PARENT'S ADDRESS (Street address, rural route, or P.O. box, Apt. No.,
City, State, ZIP Code and Country)

15A. PARENT'S NAME? (First, Middle, Last)

15C. PARENT'S DATE OF BIRTH (MM,DD,YYYY)

15D. PARENT'S DATE OF DEATH (MM,DD,YYYY)

15E. PARENT'S SOCIAL SECURITY NUMBER

(If deceased, complete Item 15D)
15F. PARENT'S TELEPHONE NUMBER(S) (Include Area Code)

15G. PARENT'S EMAIL ADDRESS (If applicable)

Daytime:
Evening:
16B. PARENT'S ADDRESS (Street address, rural route, or P.O. box, Apt. No.,
City, State, ZIP Code and Country)

16A. PARENT'S NAME? (First, Middle, Last)

16C. PARENT'S DATE OF BIRTH (MM,DD,YYYY)

16D. PARENT'S DATE OF DEATH (MM,DD,YYYY)

16E. PARENT'S SOCIAL SECURITY NUMBER

(If deceased, complete Item 16D)
16F. PARENT'S TELEPHONE NUMBER(S) (Include Area Code)

Daytime:
Evening:

16G. PARENT'S EMAIL ADDRESS (If applicable)

17A. WAS THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL
CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE AGE OF MAJORITY?
YES

NO

(If "NO," answer Items 17B through 17D)

17B. DATE(S) OF PARENTAL CONTROL (MM,DD,YYYY)
From:

To:

From:

To:

17C. WHY WASN'T THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE
AGE OF MAJORITY? (Explain fully)

17D. NAME AND ADDRESS OF EACH PERSON WHO ASSUMED PARENTAL CONTROL OVER THE VETERAN OUTSIDE THE DATE(S) SHOWN IN ITEM 17B.

SECTION IV: VETERAN'S PARENT(S) MARITAL HISTORY
18A. WHAT IS YOUR MARITAL STATUS? (Check one)
MARRIED AND LIVE WITH OTHER PARENT OF VETERAN
MARRIED AND LIVE WITH SPOUSE WHO IS NOT THE OTHER PARENT OF VETERAN
SEPARATED, MARRIED BUT NOT LIVING WITH SPOUSE, IF CHECKED PROVIDE DATE OF SEPARATION:
What was the cause of the separation? Give the reason, date(s), and duration of the separation. If the separation was by court order, attach a copy of the order.

DIVORCED, IF CHECKED PROVIDE DATE OF DIVORCE:
WIDOWED, IF CHECKED PROVIDE DATE OF DEATH OF YOUR SPOUSE:
NEVER MARRIED, IF CHECKED SKIP TO SECTION V
18D. SPOUSE'S SOCIAL SECURITY NUMBER

18B. WHAT IS YOUR SPOUSE'S NAME (First, Middle, Last)

18C. SPOUSE'S DATE OF BIRTH (MM,DD,YYYY)

18E. IS YOUR SPOUSE ALSO A VETERAN?

18F. WHAT IS YOUR SPOUSE'S VA FILE NUMBER (If any)

YES

NO

(If "Yes," answer Item 18F)

VA FORM 21P-535, XXX XXXX

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Veteran's Social Security No.

SECTION V: INFORMATION REGARDING PARENT'S NEED FOR NURSING HOME CARE OR AID AND ATTENDANCE
19. ARE YOU CLAIMING THE AID AND ATTENDANCE ALLOWANCE BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON OR HAVE SEVERE
VISUAL PROBLEMS?
YES

(If "No," skip to Section VI)

NO

NOTE: If you answered "Yes," to Item 19 and are not in a nursing home, submit a statement from your doctor showing the extent of
your disabilities. If you are in a nursing home, attach a statement signed by an official of the nursing home showing the date you were
admitted to the nursing home, the level of care you receive, and the amount you pay-out-of-pocket for your care.
20A. ARE YOU NOW IN A NURSING HOME?
YES

20B. PROVIDE THE NAME AND COMPLETE MAILING ADDRESS OF THE NURSING HOME

(If "Yes," answer Item 20B also)

NO

SECTION VI: INFORMATION REGARDING PARENT'S INCOME
IMPORTANT - Payments from any source will be counted, unless the law indicates that they don't need to be counted. Report all income in the boxes
below, and VA will determine any amount that does not count.
21. HAVE YOU CLAIMED OR ARE YOU
RECEIVING BENEFITS FROM THE SOCIAL
SECURITY ADMINISTRATION?
YES

NO

22. HAVE YOU FILED A CLAIM FOR COMPENSATION FROM
THE OFFICE OF WORKER'S COMPENSATION
PROGRAMS BASED ON THE DEATH OF THE VETERAN?
YES

NO

23. HAS A COURT AWARDED DAMAGES BASED ON
THE DEATH OF THE VETERAN OR IS A CLAIM
OR LEGAL ACTION FOR DAMAGES PENDING?
YES

NO

Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same income in both tables.
If you expect to receive a payment, but you don't know how much it will be, write "Unknown" in the space.
If you do not receive any payments from one of the sources that we list, write "0" or "None" in the space.
VA will interpret a blank space to mean "0" or "None".
If you are receiving monthly benefits, give us a copy of your most recent award letter. This will help us determine the amount of benefits you should
be paid.
Monthly Income - Report The Income You And Your Spouse Receive Monthly
Note: If you are filing this application as the guardian or custodian of the veteran's parent, do not report your own income.

Sources of recurring monthly income
24a. Social Security

Spouse

Parent
$

(If living together)
$

24b. U.S. Civil Service
24c. U.S. Railroad Retirement
24d. Military Retirement
24e. Black Lung Benefits
24f. Other income received monthly (Please write source below)

24g. Other income received monthly (Please write source below)

Annual Income By Calendar Year - Tell Us About Annual Income For You And Your Spouse
NOTE: Report income received from January 1 to the date of the veteran's death. If the claim is filed more than one year after the veteran died, report
the income you received from January 1 to the date you sign this application.

Sources of recurring monthly income
25a. Gross wages and salary

Spouse

Parent
$

(If living together)
$

25b. Total dividends and interest
25c. Life insurance
25d. Other income expected (Please write source below)

VA FORM 21P-535, XXX XXXX

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Veteran's Social Security No.

SECTION VII: INFORMATION REGARDING MEDICAL, LAST ILLNESS AND BURIAL OR OTHER REIMBURSED EXPENSES
Family medical expenses and certain other expenses actually paid by you may be deductible from your income. Show the amount of
any continuing family medical expenses such as the monthly Medicare deduction or nursing home fees you pay. Also, show
unreimbursed last illness and burial expenses you paid. Last illness and burial expenses are unreimbursed amounts paid by you for the
last illness and burial of the veteran or your spouse at any time prior to the end of the year following the year of death. Show medical,
legal or other expenses you paid because of a claim for compensation for injury or death for which civilian disability or death benefits
have been awarded. When determining your countable income, we may be able to deduct these expenses from the disability benefits
for the year in which the expenses are paid. Do not include any expenses for which you were reimbursed. If you receive
reimbursement after you have filed this claim, promptly advise the VA office handling your claim. If more space is needed,use Remarks,
Item 34, or attach a separate sheet.
26a. Amount paid by
you

26b. Date Paid
(MM,DD,YYYY)

26c. Purpose
(Medicare deduction,
doctor's fees, burial
expenses, etc.)

26d. Paid To
(Name of Doctor,
hospital, pharmacy, etc.)

26e. Relationship of person
for whom expenses were paid

SECTION VIII: DIRECT DEPOSIT INFORMATION
The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To
enroll in direct deposit, provide the information requested below, and attach either a voided personal check or a deposit slip. If you do not have
a bank account, please visit https://www.benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits
Banking Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not
to enroll, you must contact representatives handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will
encourage your participation in EFT and address any questions or concerns you may have.
NOTE: You can either attach a voided check, or answer Items 27, 28 and 29.
27. ACCOUNT NUMBER (Please check the appropriate box and provide that account number, if applicable)

Checking
Savings

I certify that I do not have an account with a financial institution
or certified payment agent

Account number
28. NAME OF FINANCIAL INSTITUTION

29. ROUTING OR TRANSIT NUMBER

VA FORM 21P-535, XXX XXXX

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Veteran's Social Security No.

SECTION IX: CERTIFICATION AND SIGNATURE

I certify and authorize the release of information:
I certify that the statements in this document are true and complete to the best of my knowledge. I authorize any person or entity,
including but not limited to any organization, service provider, employer, or government agency, to give the Department of Veterans
Affairs any information about me except protected health information, and I waive any privilege which makes the information
confidential.
30a. SIGNATURE OF PARENT, FOSTER PARENT, GUARDIAN OR CUSTODIAN (Sign in ink)

30b. DATE SIGNED

31a. SIGNATURE OF PARENT, FOSTER PARENT, GUARDIAN OR CUSTODIAN (Sign in ink)

31b. DATE SIGNED

NOTE: 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.
32a. SIGNATURE OF WITNESS (If claimant signed above using an "X") (Sign in ink)

32b. PRINTED NAME AND ADDRESS OF WITNESS

33a. SIGNATURE OF WITNESS (If claimant signed above using an "X") (Sign in ink)

33b. PRINTED NAME AND ADDRESS OF WITNESS

SECTION X: REMARKS
34. 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)

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

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-535, XXX XXXX

Page 7

Form Approved
OMB Control No. 0960-0062

SOCIAL SECURITY ADMINISTRATION

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

APPLICATION FOR SURVIVORS BENEFITS

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)
IMPORTANT-- Read instructions before completing form. Detach and retain ONLY the
instruction sheet
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.
3. SOCIAL SECURITY NO. OF
VETERAN

4. DATE OF BIRTH

6. NAME OF PARENT

5. PLACE OF BIRTH

7. MAIDEN NAME OF PARENT

8. DID THE VETERAN WORK IN THE RAILROAD INDUSTRY
AT ANY TIME AFTER 1936?
YES

NO

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the
military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric
Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.
9B. SERVICE NO.

9A. DATE ENTERED ACTIVE
SERVICE

10. RELATIONSHIP OF APPLICANT TO VETERAN
SURVIVING SPOUSE
OR SURVIVING
DIVORCED SPOUSE

CHILD

9D. GRADE, RANK, OR RATING,
ORGANIZATION AND BRANCH
OF SERVICE

9C. DATE SEPARATED
FROM ACTIVE SERVICE

11. DATE OF BIRTH OF APPLICANT

12. VA FILE NO.

PARENT

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including
stepgrandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c)
disabled or handicapped (18 or over and disability began before age 22).
13A.

13B.

13C.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a
right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I
have given in this document is true.
14. DATE (Month, day, year)

15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)
SIGN
HERE

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code)

Form SSA-24 (04-2014)
Destroy All Prior Editions

Page 1

17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS (Sign in ink)

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS (Sign in ink)

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
20. PROOFS RECEIVED
DEATH

21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)
MARRIAGE

AGE

DEATH

(NAME)

OTHER (Specify)

22. DATE

AGE

MARRIAGE

(NAME)

OTHER (Specify)

(NAME)

(NAME)

(NAME)

(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)

This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the Social
Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the application requests
information in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete part or
all of the SSA-24. However, it is usually to your advantage to provide the information because not providing it
could prevent and accurate and timely decision on your claim or could result in the loss of some benefits or
insurance coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to the Social
Security Administration and used by them to determine whether social security benefits may be payable to
surviving dependent(s) of the veteran. Social Security will then contact you regarding any social security benefits
payable based on information given on this form.
If you should have any question about entitlement to social security benefits or the information you have provided
on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When signed and
dated the form SHOULD BE LEFT ATTACHED to your completed
• VA FORM 21P-534, Application for Dependency and Indemnity Compensation,
Death Pension and Accrued Benefits by a Surviving Spouse or Child (Including
Death Compensation if Applicable) or
• VA FORM 21P-535, Application for Dependency and Indemnity Compensation by
Parent(s) (Including Accrued Benefits and Death Compensation When
Applicable).

Form SSA-24 (04-2014)

Page 2

Privacy Act Statement
Collection and Use of Personal Information

Section 202(o) of the Social Security Act, as amended, authorizes us to collect this information. We will use the
information you provide to determine whether social security benefits may be payable to survivors of a veteran.
The information you furnish on this form is voluntary. However, failure to provide the requested information could
prevent an accurate and timely decision on your claim or could result in the loss of some benefits or insurance
coverage.
We generally use the information you supply to determine whether social security benefits may be payable to
survivors of a veteran. However, we may use it for the administration and integrity of Social Security programs.
We may also disclose information to another person or to another agency in accordance with approved routine
uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of
Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State or local government agencies. Information from these matching
programs can be used to establish or verify a person's eligibility for Federally funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Additional information about this form, and any other information regarding our systems and programs, is
available on-line at www.socialsecurity.gov or at your local Social Security office.

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will
take about 15 minutes to read the instructions, gather the necessary facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-24 (04-2014)

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