VA Form 21-4170 Statement of Marital Relationship

VA Form 21-4170 or the "Statement Of Marital Relationship" is a form issued by the U.S. Department of Veterans Affairs.

The form was last revised in December 1, 2017 and is available for digital filing. Download an up-to-date VA Form 21-4170 in PDF-format down below or look it up on the U.S. Department of Veterans Affairs Forms website.

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OMB Control No. 2900-0114
Respondent Burden: 25 Minutes
Expiration Date: 11/30/2020
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
(First, Middle Initial, Last)
1. NAME OF VETERAN
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
(First, Middle Initial, Last)
7. NAME OF SPOUSE OR SURVIVING SPOUSE
8. SOCIAL SECURITY NUMBER OF SPOUSE OR
9. DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE
SURVIVING SPOUSE
(MM/DD/YYYY)
(Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
10. COMPLETE ADDRESS OF VETERAN OR CLAIMANT
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
SECTION III - INFORMATION ABOUT THE MARITAL RELATIONSHIP CLAIMED
(First, Middle
11B. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE
11A. DATE YOU BEGAN LIVING AS HUSBAND
Initial, Last)
MM/DD/YYYY)
AND WIFE (
(Include number and street or rural route, city or P. O.,
11C. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE
State and ZIP Code)
No. &
Street
City
Apt./Unit Number
Country
State/Province
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?
21-4170
SUPERSEDES VA FORM 21-4170, SEP 2014,
Page 1
VA FORM
DEC 2017
WHICH WILL NOT BE USED.
OMB Control No. 2900-0114
Respondent Burden: 25 Minutes
Expiration Date: 11/30/2020
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
(First, Middle Initial, Last)
1. NAME OF VETERAN
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
(First, Middle Initial, Last)
7. NAME OF SPOUSE OR SURVIVING SPOUSE
8. SOCIAL SECURITY NUMBER OF SPOUSE OR
9. DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE
SURVIVING SPOUSE
(MM/DD/YYYY)
(Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
10. COMPLETE ADDRESS OF VETERAN OR CLAIMANT
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
SECTION III - INFORMATION ABOUT THE MARITAL RELATIONSHIP CLAIMED
(First, Middle
11B. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE
11A. DATE YOU BEGAN LIVING AS HUSBAND
Initial, Last)
MM/DD/YYYY)
AND WIFE (
(Include number and street or rural route, city or P. O.,
11C. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE
State and ZIP Code)
No. &
Street
City
Apt./Unit Number
Country
State/Province
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?
21-4170
SUPERSEDES VA FORM 21-4170, SEP 2014,
Page 1
VA FORM
DEC 2017
WHICH WILL NOT BE USED.
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
ENDING DATE
REASON FOR SEPARATION
(MM/DD/YYYY)
(MM/DD/YYYY)
13. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE
ENDING DATE
BEGINNING DATE
(Street address, city, and State)
ADDRESS
(MM/DD/YYYY)
(MM/DD/YYYY)
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)
(First, Middle Initial, Last)
(City/State or Country)
14B. FULL NAME OF CHILD
14C. PLACE OF BIRTH
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?
(If "Yes," complete Items 15B through 15M) (If "No," skip to Item 16A)
YES
NO
VA FORM 21-4170, DEC 2017
Page 2
VETERAN'S SOCIAL SECURITY NUMBER
15C. PLACE
15D. TO WHOM MARRIED
15B. DATE OF MARRIAGE
(City/State or country)
(MM/DD/YYYY)
(First, Middle Initial, Last)
15G. HOW MARRIAGE ENDED
15E. DATE MARRIAGE ENDED
15F. PLACE
(Death,
(MM/DD/YYYY)
(City/State or country)
divorce, etc.)
15I. PLACE
15H. DATE OF MARRIAGE
15J. TO WHOM MARRIED
(City/State or country)
(MM/DD/YYYY)
(First, Middle Initial, Last)
15M. HOW MARRIAGE ENDED
15L. PLACE
15K. DATE MARRIAGE ENDED
(Death,
(MM/DD/YYYY)
(City/State or country)
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)
16C. PLACE
16D. TO WHOM MARRIED
16B. DATE OF MARRIAGE
(City/State or country)
(MM/DD/YYYY)
(First, Middle Initial, Last)
16G. HOW MARRIAGE ENDED
16E. DATE MARRIAGE ENDED
16F. PLACE
(Death,
(MM/DD/YYYY)
(City/State or country)
divorce, etc.)
16H. DATE OF MARRIAGE
16I. PLACE
16J. TO WHOM MARRIED
(MM/DD/YYYY)
(City/State or country)
(First, Middle Initial, Last)
16M. HOW MARRIAGE ENDED
16L. PLACE
16K. DATE MARRIAGE ENDED
(Death,
(MM/DD/YYYY)
(City/State or country)
divorce, etc.)
(If any)
17. REMARKS
VA FORM 21-4170, DEC 2017
Page 3
VETERAN'S SOCIAL SECURITY NUMBER
(Continued)
17. REMARKS
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.
18B. DATE SIGNED
(Sign in ink)
18A. SIGNATURE OF VETERAN
(Sign in ink)
19B. DATE SIGNED
19A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE
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.
(Sign in ink)
Number and street, City, State and ZIP Code)
20A. SIGNATURE OF WITNESS
20B. ADDRESS OF WITNESS (
(Number and street, City, State and ZIP Code)
(Sign in ink)
21B. ADDRESS OF WITNESS
21A. SIGNATURE 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.
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, DEC 2017
Page 4

Download VA Form 21-4170 Statement of Marital Relationship

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