Fillable Printable Vba 21 534A Are
Fillable Printable Vba 21 534A Are
Vba 21 534A Are
RELATIONSHIP TO CLAIMANT
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION BY A SURVIVING
SPOUSE OR CHILD - IN-SERVICE DEATH ONLY
3. CLAIMANT'S FIRST - MIDDLE- LAST NAME 4. CLAIMANT'S SOCIAL SECURITY NO.
NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other service-connected
death benefits to which you and/or the deceased veteran's children may be entitled.
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, and 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 VA.
PLACE OF BIRTH
(City and State)
1. VETERAN'S FIRST - MIDDLE- LAST NAME 2. VETERAN'S SOCIAL SECURITY NO.
5. FOR SURVIVING SPOUSE ONLY:
If not, answer Item 6.
7. DATE OF BIRTH OF SURVIVING
SPOUSE (Mo., Day, Yr.)
8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
FULL NAME
DATE OF BIRTH
(Mo., Day, Yr.)
SOCIAL SECURITY
NUMBER
9. CLAIMANT'S CURRENT MAILING ADDRESS
DAYTIME
10. CLAIMANT'S TELEPHONE NUMBERS (Including Area Code)
EVENING
12. CLAIMANT'S NEW ADDRESS 13. DATE OF ADDRESS CHANGE
14. I
CHECKING
SAVING
ACCOUNT NUMBER
FINANCIAL INSTITUTION'S NINE-DIGIT ROUTING OR TRANSIT NUMBER
15. ACCOUNT
I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
16. SIGNATURE OF CLAIMANT
OMB. Approved No. 2900-0004
Respondent Burden: 15 Minutes
Expiration Date: 1/31/2015
17. DATE SIGNED
18. NAME AND RANK OF MILITARY
CASUALTY ASSISTANCE OFFICER (CAO)
19. TELEPHONE NUMBER OF CAO 20. E-MAIL ADDRESS OF CAO
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.
VA FORM
JUN 2014
21-534a
6. CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order,
attach a copy of such order.)
I have have not lived continuously with the veteran from date of marriage to date of death.
11.
will will not be changing my address.
want
do not want my VA payment to be directly deposited to my financial account.
Respondent Burden: We need this information to determine eligibility for service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 15 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.
SUPERSEDES VA FORM 21-534A, OCT 2011,
WHICH WILL NOT BE USED.
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I
INSTRUCTIONS FOR VA FORM 21-534a
PRINT ALL ANSWERS CLEARLY.
SIGN AND DATE THE APPLICATION.
MAKE A PHOTOCOPY OF THIS APPLICATION AND EVERYTHING YOU SUBMIT TO VA BEFORE YOU MAIL IT.
NOTE - All the information requested must be answered fully and clearly or action on your claim may be delayed. If you do not know
the answer, write "unknown."
SPECIFIC INSTRUCTIONS
ITEMS 1-2 - Self-explanatory.
ITEM 3 - Name of surviving spouse or person applying on behalf of minor children.
ITEMS 4-12 -Self-explanatory.
ITEM 13 - Expected date that new mailing address will be effective.
ITEMS 14-17 - Self-explanatory.
ITEMS 18-20 - To be completed by Military Casualty Assistance Officer.
MINORS AND INCOMPETENT PERSONS - If the person for whom the claim is being made is a minor or incompetent person,
the application 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 minor or incompetent person.
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. ยง 103(c)). Additional guidance on
when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
THIS FORM, ALONG WITH THE SERVICE MEMBER'S DD FORM 1300, REPORT OF CASUALTY, SHOULD BE MAILED
OR FAXED TO:
DEPARTMENT OF VETERANS AFFAIRS
REGIONAL OFFICE AND INSURANCE CENTER
P.O. BOX 8079
PHILADELPHIA, PA 19101
FAX NUMBER (215) 381-3084.
For assistance in completing this application, or information about VA benefits and services, call us toll-free at
1-800-827-1000 (Hearing Impaired--TDD Line 1-800-829-4833).
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VA FORM 21-534a, JUN 2014
