VA Form 21P-4171 "Supporting Statement Regarding Marriage"

VA Form 21P-4171 or the "Supporting Statement Regarding Marriage" is a form issued by the United States Department of Veterans Affairs.

The latest fillable PDF version of the VA 21P-4171 was issued on March 1, 2018 and can be downloaded down below or found on the Veterans Affairs Forms website.

ADVERTISEMENT

Download VA Form 21P-4171 "Supporting Statement Regarding Marriage"

841 times
Rate
(4.6 / 5) 49 votes
OMB Control No. 2900-0115
Respondent Burden: 20 Minutes
Expiration Date: 03/31/2021
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 and give your comments or ask for mailing information on where to send your comments.
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.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
2B. VA FILE NUMBER (If applicable)
2A. VETERAN'S SOCIAL SECURITY NUMBER
C/CSS-
3. 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)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
6A. HOW LONG HAD/HAVE
5A. WHAT WAS/IS YOUR RELATIONSHIP
5B. WHAT WAS / IS YOUR
6B. HOW LONG HAD/HAVE
YOU KNOWN THE
RELATIONSHIP TO THE
YOU KNOWN THE
TO THE VETERAN? (Parent, child, brother,
VETERAN? (Months,
CLAIMED SPOUSE? (Parent, child,
CLAIMED SPOUSE?
sister, etc. If not related, state "None")
years)
brother, sister, etc. If not related,
(Months, years)
state "None")
7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?
7A. HOW OFTEN 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
9. DID/DO EITHER THE VETERAN OR CLAIMED SPOUSE EVER DENY
THE MARRIAGE?
GENERALLY KNOWN AS MARRIED?
NO
YES
YES
NO
(If additional
10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMED
10B. PROVIDE FACTS AND REASONS FOR SUCH BELIEF
space needed use Item 17, "Remarks" )
SPOUSE TO BE MARRIED?
(If "Yes," complete Item 10B
)
NO
YES
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?
(If "Yes," complete Items 12B and 12C)
YES
NO
12B. DATE
12C. PLACE
SUPERSEDES VA FORM 21-4171, NOV 2013,
VA FORM
Page 1
21P-4171
WHICH WILL NOT BE USED.
MAR 2018
OMB Control No. 2900-0115
Respondent Burden: 20 Minutes
Expiration Date: 03/31/2021
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 and give your comments or ask for mailing information on where to send your comments.
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.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
2B. VA FILE NUMBER (If applicable)
2A. VETERAN'S SOCIAL SECURITY NUMBER
C/CSS-
3. 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)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
6A. HOW LONG HAD/HAVE
5A. WHAT WAS/IS YOUR RELATIONSHIP
5B. WHAT WAS / IS YOUR
6B. HOW LONG HAD/HAVE
YOU KNOWN THE
RELATIONSHIP TO THE
YOU KNOWN THE
TO THE VETERAN? (Parent, child, brother,
VETERAN? (Months,
CLAIMED SPOUSE? (Parent, child,
CLAIMED SPOUSE?
sister, etc. If not related, state "None")
years)
brother, sister, etc. If not related,
(Months, years)
state "None")
7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?
7A. HOW OFTEN 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
9. DID/DO EITHER THE VETERAN OR CLAIMED SPOUSE EVER DENY
THE MARRIAGE?
GENERALLY KNOWN AS MARRIED?
NO
YES
YES
NO
(If additional
10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMED
10B. PROVIDE FACTS AND REASONS FOR SUCH BELIEF
space needed use Item 17, "Remarks" )
SPOUSE TO BE MARRIED?
(If "Yes," complete Item 10B
)
NO
YES
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?
(If "Yes," complete Items 12B and 12C)
YES
NO
12B. DATE
12C. PLACE
SUPERSEDES VA FORM 21-4171, NOV 2013,
VA FORM
Page 1
21P-4171
WHICH WILL NOT BE USED.
MAR 2018
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?
(If "Yes," complete Item 13B)
YES
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?
(If "Yes," complete Item 14B)
NO
YES
14B. EXPLANATION
15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 15B)
YES
NO
15B. OTHER MARRIAGES OF VETERAN
HOW MARRIAGE
DATE AND PLACE
TYPE OF MARRIAGE
DATE AND PLACE
TO WHOM MARRIED
ENDED
OF MARRIAGE
(Ceremonial, etc.)
MARRIAGE ENDED
(Death, divorce, etc.)
16A. HAS THE CLAIMED SPOUSE EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 16B)
NO
YES
16B. OTHER MARRIAGES OF CLAIMED SPOUSE
HOW MARRIAGE
DATE AND PLACE
TYPE OF MARRIAGE
DATE AND PLACE
TO WHOM MARRIED
ENDED
(Ceremonial, etc.)
OF MARRIAGE
MARRIAGE ENDED
(Death, divorce, etc.)
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)
(Including Area Code)
(Including Area Code)
18C. DAYTIME TELEPHONE NUMBER
18D. EVENING TELEPHONE NUMBER
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.
VA FORM 21P-4171, MAR 2018
Page 2
FOR VETERANS PENSION AND SURVIVOR BENEFIT CLAIMS MAIL OR FAX THIS FORM TO THE APPROPRIATE
ADDRESS BELOW:
Mail your form to:
Mail your form to:
Department of Veterans Affairs
Department of Veterans Affairs
Claims Intake Center
Claims Intake Center
Attn: Milwaukee Pension Center
Attn: St. Paul Pension Center
P.O. Box 5192
P.O. Box 5365
Janesville, WI 53547-5192
Janesville, WI 53547-5365
Or fax your form to:
Or fax your form to:
Toll Free: (844) 655-1604
Toll Free: (844) 655-1604
This Pension Center Serves The Following:
This Pension Center Serves The Following:
Alabama
Arkansas
Illinois
Indiana
Alaska
Arizona
California
Colorado
Kentucky
Louisiana
Michigan
Mississippi
Hawaii
Idaho
Iowa
Kansas
Missouri
Ohio
Tennessee
Wisconsin
Minnesota
Montana
Nebraska
Nevada
New
North
Oklahoma
Oregon
Mail your form to:
Mexico
Dakota
Department of Veterans Affairs
South
Texas
Utah
Washington
Claims Intake Center
Dakota
Attn: Philadelphia Pension Center
Central
South
Wyoming
Mexico
P.O. Box 5206
America
America
Janesville, WI 53547-5206
Or fax your form to:
Caribbean
Toll Free: (844) 655-1604
This Pension Center Serves The Following:
Connecticut
Delaware
F
G
lorida
eorgia
New
Maine
Maryland
Massachusetts
Hampshire
North
New Jersey
New York
Pennsylvania
Carolina
Rhode
South
Vermont
Virginia
Island
Carolina
West
District of
Puerto Rico
Canada
Virginia
Columbia
Countries outside of North, Central or South America
Page 3
VA Form 21P-4171, MAR 2018
ADVERTISEMENT
Page of 3