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Federal forms, ICRs, and supporting documents

OMB control number

Statement of Marital Relationship (VA Form 21-4170)

OMB 2900-0114 ยท VA.

OMB 2900-0114

VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

The latest form for Statement of Marital Relationship (VA Form 21-4170) expires 2027-08-31 and is listed under ICR 202404-2900-005.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 21-4170 Statement of Marital Relationship (VA Form 21-4170)Form
2024-14840, 30-Day FRN (2900-0114, VAF21-4170).pdf Supplementary Document
2024-09321, 60-Day FRN (VAF21-4170).pdf Supplementary Document
2900-0114, Supporting Statement (VAF21-4170).docxSupporting Statement A
Statement of Marital Relationship (VA Form 21-4170) Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202404-2900-005 Revision of a currently approved collection 2024-07-09 Approved without change
202009-2900-015 Reinstatement with change of a previously approved collection 2021-05-24 Approved without change
201611-2900-010 Extension without change of a currently approved collection 2017-09-22 Approved without change
201312-2900-015 Revision of a currently approved collection 2014-07-08 Approved without change
201103-2900-008 Extension without change of a currently approved collection 2011-07-18 Approved without change
200709-2900-016 Extension without change of a currently approved collection 2008-05-23 Approved without change
200503-2900-015 Revision of a currently approved collection 2005-03-17 Approved with change
200202-2900-011 Extension without change of a currently approved collection 2002-02-11 Approved with change
200201-2900-035 Extension without change of a currently approved collection 2002-01-18 Withdrawn and continue
200004-2900-004 Extension without change of a currently approved collection 2000-04-28 Approved without change
199701-2900-001 Extension without change of a currently approved collection 1997-01-24 Approved without change
199311-2900-010 Extension without change of a currently approved collection 1993-11-08 Approved without change
199009-2900-002 Reinstatement with change of a previously approved collection 1990-09-21 Approved without change
198906-2900-018 No material or nonsubstantive change to a currently approved collection 1989-06-27 Approved with change
198904-2900-031 No material or nonsubstantive change to a currently approved collection 1989-04-06 Approved with change
198709-2900-002 Reinstatement with change of a previously approved collection 1987-09-11 Approved without change
198409-2900-003 Reinstatement with change of a previously approved collection 1984-09-04 Approved without change
198107-2900-013 Extension without change of a currently approved collection 1981-07-01 Approved without change
198011-2900-072 No material or nonsubstantive change to a currently approved collection 1980-11-06 Approved with change
197609-2900-004 Revision of a currently approved collection 1976-09-07 Approved without change