Form VA Form 21-4170 VA Form 21-4170 Statement of Marital Relationship

OMB Control No. 2900-0114
Respondent Burden: 25 Minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

STATEMENT OF MARITAL RELATIONSHIP
INSTRUCTIONS: This form is to be completed by the veteran (if living) and the person who is claiming to be the
spouse or surviving spouse. Note: For the purposes of this form, the person who is claiming to be the spouse or
surviving spouse is referred to as "spouse or surviving spouse." Print all answers clearly. 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 17, "Remarks, " or attach a separate sheet, indicating the item number to which the answers apply.
IMPORTANT INFORMATION: Submit any documents that show the veteran and the spouse or surviving spouse as husband and wife; for example, lease
agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Please be
advised that original documents will not be returned to you. We highly encourage you to submit certified copies instead.
SECTION I - INFORMATION ABOUT THE VETERAN
1. NAME OF VETERAN (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable) 6A. PREFERRED TELEPHONE NUMBER (Include Area Code) 6B. ALTERNATE TELEPHONE NUMBER(Include Area Code)

SECTION II - INFORMATION ABOUT THE SPOUSE OR SURVIVING SPOUSE
7. NAME OF SPOUSE OR SURVIVING SPOUSE (First, Middle Initial, Last)

8. SOCIAL SECURITY NUMBER OF SPOUSE OR
SURVIVING SPOUSE

9. DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE
(MM/DD/YYYY)

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

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

SECTION III - INFORMATION ABOUT THE MARITAL RELATIONSHIP CLAIMED
11A. DATE YOU BEGAN LIVING AS HUSBAND
AND WIFE (MM/DD/YYYY)

11B. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE (First, Middle

Initial, Last)

11C. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE (Include number and street or rural route, city or P. O.,

State and ZIP Code)

No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE:
11D. AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?

ALWAYS

SOMETIMES

NEVER

11E. WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE TIME YOU BEGAN LIVING TOGETHER?

VA FORM
XXX XXXX

21-4170

SUPERSEDES VA FORM 21-4170, DEC 2017,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NUMBER
11F. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?
YES

NO

(If "Yes," skip to Item 13)( If "No," complete Item 12)
12. LIST ALL PERIODS OF SEPARATION

BEGINNING DATE

(MM/DD/YYYY)

ENDING DATE

REASON FOR SEPARATION

(MM/DD/YYYY)

13. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE
BEGINNING DATE

(MM/DD/YYYY)

ENDING DATE

(MM/DD/YYYY)

ADDRESS (Street address, city, and State)

SECTION IV - INFORMATION ABOUT YOUR CHILDREN

IMPORTANT INFORMATION: Send a certified copy of the public record of birth for each child listed in Item 14B.

14A. HAVE YOU HAD CHILDREN TOGETHER?
YES

NO

(If "Yes," complete Item 14B) (If "No," skip to Item 15A)

14B. FULL NAME OF CHILD (First, Middle Initial, Last)

14C. PLACE OF BIRTH (City/State or Country)

SECTION V - INFORMATION ABOUT YOUR MARITAL HISTORY

INSTRUCTIONS: Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional space,
please attach a separate sheet of paper providing the requested information about the marriages.
IMPORTANT INFORMATION: Attach copies of divorce decrees.
15A. HAS (HAD) THE VETERAN EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

NO

(If "Yes," complete Items 15B through 15M) (If "No," skip to Item 16A)

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VETERAN'S SOCIAL SECURITY NUMBER

15B. DATE OF MARRIAGE

(MM/DD/YYYY)

15E. DATE MARRIAGE ENDED

(MM/DD/YYYY)

15H. DATE OF MARRIAGE

15C. PLACE

(City/State or country)

15F. PLACE

(City/State or country)

15I. PLACE

(MM/DD/YYYY)

(City/State or country)

15K. DATE MARRIAGE ENDED

15L. PLACE

(MM/DD/YYYY)

(City/State or country)

15D. TO WHOM MARRIED

(First, Middle Initial, Last)

15G. HOW MARRIAGE ENDED

(Death,
divorce, etc.)

15J. TO WHOM MARRIED

(First, Middle Initial, Last)

15M. HOW MARRIAGE ENDED

(Death,
divorce, etc.)

16A. HAS THE SPOUSE OR SURVIVING SPOUSE EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

NO

(If "Yes," complete Item 16B through 16M) (If "No," skip to Item 17)

16B. DATE OF MARRIAGE

16C. PLACE

(MM/DD/YYYY)

(City/State or country)

16E. DATE MARRIAGE ENDED

16F. PLACE

(MM/DD/YYYY)

16H. DATE OF MARRIAGE

(MM/DD/YYYY)

16K. DATE MARRIAGE ENDED

(MM/DD/YYYY)

(City/State or country)

16I. PLACE

16D. TO WHOM MARRIED

(First, Middle Initial, Last)

16G. HOW MARRIAGE ENDED

(Death,
divorce, etc.)

16J. TO WHOM MARRIED

(City/State or country)

(First, Middle Initial, Last)

16L. PLACE

16M. HOW MARRIAGE ENDED

(City/State or country)

(Death,
divorce, etc.)

17. REMARKS (If any)

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VETERAN'S SOCIAL SECURITY NUMBER
17. REMARKS (Continued)

SECTION VI - CERTIFICATION AND SIGNATURE(S)

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.
18A. SIGNATURE OF VETERAN (Sign in ink)

18B. DATE SIGNED

19A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE (Sign in ink)

19B. DATE SIGNED

SECTION VII-WITNESSES TO SIGNATURE(S) IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the veteran or the claimed spouse or surviving spouse is personally known and the signatures
and addresses of the witnesses must be entered below.
20A. SIGNATURE OF WITNESS (Sign in ink)

20B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

21A. SIGNATURE OF WITNESS (Sign in ink)

21B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

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.
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 USC 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 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 in order to determine continued 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 25 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 21-4170, XXX XXXX

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