Form 21P-4171 Supporting Statement Regarding Marriage

OMB Control No. 2900-0115
Respondent Burden: 20 Minutes
Expiration Date: XXXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS
SPACE)

SUPPORTING STATEMENT REGARDING MARRIAGE
Privacy Act Notice: 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 voluntary. 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 benefits based on a marital relationship between the claimant and the
veteran (38 U.S.C. 101, 103, and 1102). 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 your comments or suggestions about this form.

INSTRUCTIONS: Please complete all items. Your answer to every question is important to help us complete the claimant's 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. See page 2 for mailing
information.

1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

2B. VA FILE NUMBER (If applicable)

2A. VETERAN'S SOCIAL SECURITY NUMBER

C/CSS3. CLAIMED SPOUSE OR SURVIVING SPOUSE'S NAME (First, Middle Initial, Last)

4A. NAME OF PERSON COMPLETING THIS FORM (First, Middle Initial, Last)
4B. ADDRESS OF PERSON COMPLETING THIS FORM (Number and street, P.O. or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

5A. WHAT WAS/IS YOUR RELATIONSHIP
TO THE VETERAN? (Parent, child, brother,
sister, etc. If not related, state "None")

ZIP Code/Postal Code

5B. WHAT WAS / IS YOUR
RELATIONSHIP TO THE
CLAIMED SPOUSE? (Parent, child,
brother, sister, etc. If not related,
state "None")

6A. HOW LONG HAD/HAVE
YOU KNOWN THE
VETERAN? (Months,
years)

6B. HOW LONG HAD/HAVE
YOU KNOWN THE
CLAIMED SPOUSE?
(Months, years)

7A. HOW OFTEN HAD/HAVE YOU MET THE VETERAN?

7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?

7C. HOW OFTEN HAVE YOU MET THE CLAIMED SPOUSE?

7D. ON WHAT OCCASIONS HAVE YOU MET THE CLAIMED SPOUSE?

8. WERE/ARE THE VETERAN AND THE CLAIMED SPOUSE
GENERALLY KNOWN AS MARRIED?

9. DID/DO EITHER THE VETERAN OR CLAIMED SPOUSE EVER DENY
THE MARRIAGE?

YES

NO

YES

10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMED
SPOUSE TO BE MARRIED?
YES

NO

NO

10B. PROVIDE FACTS AND REASONS FOR SUCH BELIEF (If additional

space needed use Item 17, "Remarks" )

(If "Yes," complete Item 10B)
11. NAME(S) BY WHICH SPOUSE WAS/IS KNOWN
LAST NAME

FIRST NAME

12A. HAD/HAVE YOU EVER HEARD THE VETERAN OR THE CLAIMED SPOUSE REFER TO EACH OTHER AS MARRIED TO ONE ANOTHER?
YES

NO

(If "Yes," complete Items 12B and 12C)
12B. DATE

VA FORM
XXXX

21P-4171

12C. PLACE
SUPERSEDES VA FORM 21-4171, MAR 2018,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NO.

13A. DID/DO THE VETERAN AND THE CLAIMED SPOUSE MAINTAIN A HOME AND LIVE TOGETHER AS MARRIED TO ONE ANOTHER?
YES

(If "Yes," complete Item 13B)

NO

13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMED SPOUSE HAD/HAVE LIVED TOGETHER
BEGINNING DATE

ENDING DATE

CITY OR TOWN

STATE

14A. HAD/HAVE THE VETERAN AND THE CLAIMED SPOUSE LIVED TOGETHER CONTINUOUSLY?
YES

(If "Yes," complete Item 14B)

NO

14B. EXPLANATION
15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
YES

NO

(If "Yes," complete Item 15B)
15B. OTHER MARRIAGES OF VETERAN

TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE
ENDED

(Death, divorce, etc.)

DATE AND PLACE
MARRIAGE ENDED

16A. HAS THE CLAIMED SPOUSE EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
YES

NO

(If "Yes," complete Item 16B)

16B. OTHER MARRIAGES OF CLAIMED SPOUSE
TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE
ENDED

(Death, divorce, etc.)

DATE AND PLACE
MARRIAGE ENDED

17. REMARKS (If any)

CERTIFICATION

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief. I understand that this statement will be considered in connection
with an application for VA benefits based on a marital relationship between the veteran and the person named in Item 3.
18B. DATE SIGNED
18A. SIGNATURE (Sign in ink)
18C. DAYTIME TELEPHONE NUMBER (Including Area Code)

18D. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESS TO SIGNATURE IF MADE BY "X" MARK

NOTE: Signature by mark must be witnessed by two persons to whom the signer is personally known and the signature and addresses of the witnesses must be entered
below.
19A. SIGNATURE OF WITNESS (Sign in ink)
19B. ADDRESS OF WITNESS
20A. SIGNATURE OF WITNESS (Sign in ink)

20B. ADDRESS OF WITNESS

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.

Department of Veterans Affairs
Pension Intake Center
MAIL TO:
PO Box 5365
Janesville, WI 53547-5365
VA FORM 21P-4171, XXXX

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