VA Form 21P-534 Application for Dependency and Indemnity Compensation, Survivors Pension and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable)

What Is VA Form 21P-534?

VA Form 21P-534, Application for Dependency and Indemnity Compensation, Death Pension and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) is used by a surviving spouse or child of a deceased veteran to claim the Department of Veterans Affairs (VA) benefits they may be entitled to receive. Besides, this form may be used to apply for the accrued benefits (money that is owed to the veteran by the VA, but did not pay before the death).

The latest version of the form - formerly known as VA Form 21-534 - was released by the VA in October 2018 with previous editions obsolete. An up-to-date fillable version of VA Form 21P-534 is available for digital filing and download below or can be found on the VA website.

The application has two related forms:

You may use the first document to claim DIC, survivor pension, and/or accrued benefits when the second one is filled out in order to request benefits related with in-service death of a veteran.

ADVERTISEMENT
GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION (DIC), SURVIVORS PENSION AND ACCRUED
BENEFITS BY A SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21P-534
Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
If you have any questions about this form, how to fill it out, or about VA benefits, contact your nearest VA regional office.
You can locate the address of the nearest regional office in your telephone book blue pages under "United States Government, Veterans" or call
1-800-827-1000 (Hearing Impaired TDD line is 711). You may also contact VA by Internet at
https://iris.custhelp.com/
.
B. What is the purpose of VA Form 21P-534?
Use VA Form 21P-534 to apply for:
VA benefits you may be entitled to receive as a surviving spouse or child
of a deceased veteran, and
any money VA owes the veteran but did not pay prior to his or her death (accrued benefits).
NOTE: If you apply for any one of these benefits, the law requires that we also consider you for the others.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security (SS) benefits by using the SSA-24 form attached to this VA Form (see pages 12 and 13). You don't have to apply
if you don't want to or have already done so. If you do want to apply, fill it out and leave it attached. We will send it to the Social Security
Administration for you. They will then contact you.
D. What are dependency and indemnity compensation (DIC) and Survivors Pension benefits, and how does VA decide what I
will or will not receive?
1. Dependency and indemnity compensation may be payable when:
a veteran's death occurred while on active service, or
a veteran dies of a service-connected disability or disabilities that was/were either the principal or contributory cause of death, or
a veteran died from a non-service connected injury or disease AND was receiving, or entitled to receive VA compensation for a service-
connected disability rated totally disabling;
For at least 10 years immediately before death; or
For at least 5 years after the veteran's release from active duty preceding death; or
For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999.
2. Survivors Pension may be payable when:
the death of a veteran with wartime service is not due to service, and
income and assets are within applicable limits.
VA pays pension based on the amount of family income and assets and the number of dependent children. This is based on law. VA must include as
income all sources that Federal law specifies. If there is no surviving spouse, pension may be payable on behalf of a child or children.
You must provide information about the Social Security benefits you and your dependents receive. Report the gross amount you and your dependents
receive monthly before deductions are taken out. If you have a copy of your most recent Social Security award letter, please include a copy of the letter
with your application.
You must tell us if you or your dependents receive or received income from sources other than Social Security. Please also report if you or your
dependents own your primary residence and the value of your assets and your dependents' assets. Your assets do include your spouse's assets.
Although your assets do not include your child's assets, you must tell us if your child has significant assets.
Assets means the fair market value of all property that an individual owns, including all real and personal property (excluding the value of the primary
residence including the residential lot area, not to exceed 2 acres) less the amount of mortgages or other encombrances specific to the mortgaged or
encumbered property). Personal property means the value of personal effects that are in excess of being suitable and consistent with a reasonable mode
of life.
Unless a claim for dependency and indemnity compensation or Survivors Pension is filed within 1 year from the date of the veteran's death, that benefit
is not payable from a date earlier than the date the claim is received in the VA.
If it is determined that you are entitled to DIC and death pension, we will pay you whichever benefit entitles you to the most money. Benefit rates and
income limits are frequently changed, so it is not possible to keep this information current in these instructions. You can find out what the current
income limitations and rates of benefits are by contacting your nearest VA regional office.
21P-534
SUPERSEDES VA FORM 21-534, JUN 2018,
VA FORM
PAGE 1
General Instructions
WHICH WILL NOT BE USED.
OCT 2018
GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION (DIC), SURVIVORS PENSION AND ACCRUED
BENEFITS BY A SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21P-534
Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
If you have any questions about this form, how to fill it out, or about VA benefits, contact your nearest VA regional office.
You can locate the address of the nearest regional office in your telephone book blue pages under "United States Government, Veterans" or call
1-800-827-1000 (Hearing Impaired TDD line is 711). You may also contact VA by Internet at
https://iris.custhelp.com/
.
B. What is the purpose of VA Form 21P-534?
Use VA Form 21P-534 to apply for:
VA benefits you may be entitled to receive as a surviving spouse or child
of a deceased veteran, and
any money VA owes the veteran but did not pay prior to his or her death (accrued benefits).
NOTE: If you apply for any one of these benefits, the law requires that we also consider you for the others.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security (SS) benefits by using the SSA-24 form attached to this VA Form (see pages 12 and 13). You don't have to apply
if you don't want to or have already done so. If you do want to apply, fill it out and leave it attached. We will send it to the Social Security
Administration for you. They will then contact you.
D. What are dependency and indemnity compensation (DIC) and Survivors Pension benefits, and how does VA decide what I
will or will not receive?
1. Dependency and indemnity compensation may be payable when:
a veteran's death occurred while on active service, or
a veteran dies of a service-connected disability or disabilities that was/were either the principal or contributory cause of death, or
a veteran died from a non-service connected injury or disease AND was receiving, or entitled to receive VA compensation for a service-
connected disability rated totally disabling;
For at least 10 years immediately before death; or
For at least 5 years after the veteran's release from active duty preceding death; or
For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999.
2. Survivors Pension may be payable when:
the death of a veteran with wartime service is not due to service, and
income and assets are within applicable limits.
VA pays pension based on the amount of family income and assets and the number of dependent children. This is based on law. VA must include as
income all sources that Federal law specifies. If there is no surviving spouse, pension may be payable on behalf of a child or children.
You must provide information about the Social Security benefits you and your dependents receive. Report the gross amount you and your dependents
receive monthly before deductions are taken out. If you have a copy of your most recent Social Security award letter, please include a copy of the letter
with your application.
You must tell us if you or your dependents receive or received income from sources other than Social Security. Please also report if you or your
dependents own your primary residence and the value of your assets and your dependents' assets. Your assets do include your spouse's assets.
Although your assets do not include your child's assets, you must tell us if your child has significant assets.
Assets means the fair market value of all property that an individual owns, including all real and personal property (excluding the value of the primary
residence including the residential lot area, not to exceed 2 acres) less the amount of mortgages or other encombrances specific to the mortgaged or
encumbered property). Personal property means the value of personal effects that are in excess of being suitable and consistent with a reasonable mode
of life.
Unless a claim for dependency and indemnity compensation or Survivors Pension is filed within 1 year from the date of the veteran's death, that benefit
is not payable from a date earlier than the date the claim is received in the VA.
If it is determined that you are entitled to DIC and death pension, we will pay you whichever benefit entitles you to the most money. Benefit rates and
income limits are frequently changed, so it is not possible to keep this information current in these instructions. You can find out what the current
income limitations and rates of benefits are by contacting your nearest VA regional office.
21P-534
SUPERSEDES VA FORM 21-534, JUN 2018,
VA FORM
PAGE 1
General Instructions
WHICH WILL NOT BE USED.
OCT 2018
E. How do I apply for special monthly pension or special monthly DIC?
VA may pay increased survivor benefits to a surviving spouse who is blind, a patient in a nursing home due to mental or physical incapacity, requires
the aid of another person to perform personal functions required in everyday living, such as bathing, feeding, dressing yourself, attending to the wants
of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your daily environment (38 Code of Federal Regulations 3.352(a)); or
who is permanently confined to his or her immediate premises because of a permanent disability. If you wish to apply for this benefit, check "Yes" for
Item 31.
F. How do I complete my application?
Print all answers clearly. If an answer is "none" or "0," write that. 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 49, "Remarks, " or attach a separate sheet, indicating the item number to
which the answers apply. Make sure you sign and date this application (Items 46A and 46B).
Note: If the claim is being made on behalf of a minor or incompetent person, the application form 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.
G. What do I do when I have completed my application?
When you have completed this application mail it or take it to a VA regional office. Be sure to attach any materials that support and explain your
claim. Also, make a photocopy of your application and everything that you submit to VA before mailing it. You can find the mailing address of
your local VA regional office at www.va.gov/directory.
H. How can I assign someone to act as my representative?
A representative can be a VA accredited Veterans Service Organization or other service organization that the Secretary of Veterans Affairs
recognizes or, a VA accredited attorney or claims agent. Agents and attorneys can charge you for services that you get from them only after the
Board of Veteran's Appeals (BVA) gives you their final decision about your application. That means you can use an attorney during any stage of
your application for benefits. However, the agent or attorney cannot charge you for services unless you are trying to resolve a dispute with VA after
BVA has made a decision about your claim.
If you want to use a representative to help you with your application, contact the nearest VA office. Depending on the type of representative you
want to designate, we will send you one of the following forms:
• VA Form 21-22, Appointment of a Veterans Service Organization as Claimant's Representative, or
• VA Form 21-22A, Appointment of Individual as Claimant's Representative.
You may also download these forms at www.va.gov/vaforms. If you have already designated a representative, no further action is required on your
part.
I. What if I believe that VA has made an error in processing or deciding my benefits?
You can ask for a personal hearing at any time during the processing of your claim. That means you can ask for the hearing while VA is processing
your claim or after VA has made a decision. You should contact the nearest VA office and tell them that you want a personal hearing on your case.
Someone in the local VA office will arrange a time and place for your hearing. At this hearing, you can bring witnesses. VA will record whatever
you and your witnesses say during the hearing and include it in the official record. VA will furnish the hearing room and officials, and prepare a
transcript of the hearing. VA cannot pay your expenses or the expenses of anyone you want to bring with you to the hearing.
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 when you filed your claim (or later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance
on VA recognized marriages is available at http:www.va.gov/opa/marriage/.
PRIVACY ACT INFORMATION: The 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, 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). The 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. 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 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 to determine eligibility for death benefits and accrued benefits under 38 U.S.C. 1310 through
1314, 1532 through 1543, and 5121. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 1
hour and 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.
VA FORM 21P-534, OCT 2018
General Instructions
PAGE 2
OMB Approved No. 2900-0004
Respondent Burden: 1 hour 15 minutes
Expiration Date: 10/31/2021
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, SURVIVORS
PENSION AND ACCRUED BENEFITS BY A SURVIVING SPOUSE OR CHILD
(Including Death Compensation if Applicable)
IMPORTANT - Read the attached "General Instructions" before you fill out this form.
(DO NOT WRITE IN THIS
PART I - CLAIM INFORMATION
(Tell us what you are applying for and what you and the deceased veteran have applied for)
SPACE)
(VA DATE STAMP)
1. DID THE VETERAN EVER FILE A CLAIM WITH VA ?
2. WHAT IS THE VA FILE NUMBER? (If known)
YES
NO
(If "Yes," answer Item 2)
3. HAS THE SURVIVING SPOUSE OR CHILD EVER FILED A CLAIM WITH VA?
4. WHAT IS THE VA FILE NUMBER? (If known)
YES
NO
(If "Yes," answer Items 4 through 6)
5. WHAT IS THE NAME OF THE PERSON ON WHOSE SERVICE THE CLAIM WAS FILED? (First, Middle, Last Name of Veteran)
7. ARE YOU CLAIMING SERVICE CONNECTION FOR CAUSE OF DEATH?
6. WHAT IS YOUR RELATIONSHIP TO THAT PERSON?
YES
NO
PART II - IDENTIFYING INFORMATION (Provide information about you and the deceased veteran)
8. WHAT IS THE VETERAN'S NAME? (First, Middle, Last Name of Veteran) (Suffix - if applicable)
9. VETERAN'S SOCIAL SECURITY NO.
10B. LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER
10A. DID THE VETERAN SERVE UNDER ANOTHER NAME?
YES
NO
(If "Yes," answer Item 10B)
(Month, Day, Year)
12. WHAT IS THE VETERAN'S DATE OF DEATH (Month, Day, Year)
11. WHAT IS THE VETERAN'S DATE OF BIRTH
(NOTE: Attach a copy of the death certificate unless the veteran
died in active service of the Army, Navy, Air Force, Marine Corps,
or Coast Guard, or in a U.S. government institution)
13. WAS THE VETERAN A FORMER PRISONER OF WAR?
14. WHAT IS YOUR NAME? (First, Middle, Last Name of Veteran's Spouse or Child)
YES
NO
(Number and street or rural route, city or P.O., State,
16. WHAT IS YOUR ADDRESS
15. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
ZIP Code and Country)
SURVIVING SPOUSE
CHILD
17. WHAT ARE YOUR TELEPHONE NUMBERS? (Include Area Code)
18. WHAT IS YOUR E-MAIL ADDRESS?
DAYTIME
CELL PHONE
EVENING
(Month, Day, Year)
19. WHAT IS YOUR SOCIAL SECURITY NUMBER?
20. WHAT IS THE YOUR DATE OF BIRTH
PART III - VETERAN'S ACTIVE DUTY SERVICE
IMPORTANT: Enter complete information for all periods of service. If more space is needed use Item 49 "Remarks". If the veteran never filed a claim with
VA, attach the original DD214 or a certified copy for each period of service listed. We will return original documents to you.
21D. DATE LEFT ACTIVE
21A. ENTERED ACTIVE
21B. PLACE ENTERED ACTIVE
21C. SERVICE NUMBER
SERVICE - First Period
SERVICE - First Period
SERVICE - First Period
(Month, Day, Year)
(Month, Day, Year)
21E. PLACE LEFT ACTIVE
21G. GRADE, RANK,
21F. BRANCH OF SERVICE
SERVICE - First Period
OR RATING
21I. PLACE ENTERED ACTIVE
21K. DATE LEFT ACTIVE
21H. ENTERED ACTIVE
21J. SERVICE NUMBER
SERVICE - First Period
SERVICE - Second Period
SERVICE - Second Period
(Month, Day, Year)
(Month, Day, Year)
21L. PLACE LEFT ACTIVE
21N. GRADE, RANK,
SERVICE - Second Period
21M. BRANCH OF SERVICE
OR RATING
VA FORM
SUPERSEDES VA FORM 21-534, JUN 2018,
21P-534
PAGE 3
OCT 2018
WHICH WILL NOT BE USED.
PART IV - MARITAL INFORMATION
(Attach a copy of your marriage certificate showing your marriage to the veteran)
NOTE: You must furnish complete information about all marriages of the surviving spouse and the veteran. If you need additional space, please
attach a separate VA Form 21-686c, Declaration of Status of Dependents, providing the requested information.
If you are claiming benefits as the surviving spouse of the veteran you should complete Items 22A through 28. If you are not the surviving spouse, skip to
Section V.
TELL US ABOUT THE VETERAN'S MARRIAGES
22A. HOW MANY TIMES WAS THE VETERAN MARRIED? (Include marriage to you)
22F. DATE (month, day, year) and
22D. TYPE OF MARRIAGE
22E. HOW MARRIAGE
22B. DATE (month, day, year) and PLACE
22C. TO WHOM MARRIED
PLACE MARRIAGE TERMINATED
(ceremonial, common-law,
TERMINATED
OF MARRIAGE (city, state or country)
(first, middle, last name)
(city/state or country)
proxy, tribal, or other)
(death, divorce)
22G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22D, PLEASE EXPLAIN:
TELL US ABOUT YOUR MARRIAGES
23B. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
23A. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Include your marriage to the
veteran)
NO
YES
Provide information in Items 23c through 23G for all of your marriages)
23F. HOW MARRIAGE
23G. DATE (month, day, year)
23E. TYPE OF MARRIAGE
23C. DATE (month, day, year) and PLACE
TERMINATED
23D. TO WHOM MARRIED
and PLACE MARRIAGE
(ceremonial, common-law,
OF MARRIAGE (city/state or country)
(death, divorce, marriage has not
(first, middle, last name)
TERMINATED
proxy, tribal, or other)
been terminated)
(city/state or country)
23H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 23E, PLEASE EXPLAIN:
24. WAS A CHILD BORN TO YOU AND THE VETERAN DURING YOUR MARRIAGE
25. ARE YOU EXPECTING THE BIRTH OF THE VETERAN'S CHILD?
OR PRIOR TO YOUR MARRIAGE?
(Answer Item 24 only if you were married to the veteran
YES
NO
YES
NO
less than one year)
26. DID YOU LIVE CONTINUOUSLY WITH THE VETERAN FROM THE DATE
27. WHAT WAS THE CAUSE OF SEPARATION? GIVE THE REASON, DATE(S) AND
DURATION OF THE SEPARATION (IF THE SEPARATION WAS BY COURT ORDER,
OF MARRIAGE TO THE DATE OF HIS/HER DEATH?
ATTACH A COPY OF THE ORDER)
YES
NO
(If "No," complete Item 27)
28. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?
YES
NO
(If "Yes," provide explanation):___________________________________________________________________________________________
PART V - DEPENDENT CHILDREN (Complete ONLY if claiming benefits for a child(ren) of the veteran)
(Skip to Section VI if you are NOT claiming benefits for a child(ren) of the veteran)
TELL US ABOUT THE UNMARRIED CHILDREN OF THE VETERAN
NOTE: You should provide a copy of the public record of birth or a copy of the court record of adoption for each child listed in Item 29A unless the veteran
was receiving additional VA benefits for the child.
If you need additional space, please attach a separate VA Form 21-686c, Declaration of Status of Dependents, providing the requested information
about each child.
IMPORTANT: Skip to Part VI if you are not claiming benefits for any children that meet the following criteria.
VA recognizes the veteran's biological children, adopted children, and stepchildren as dependents. These children must be unmarried and:
∙ ∙
under age 18, or
at least 18 but under 23 and pursuing an approved course of education, or
of any age if they became permanently unable to support themselves before reaching at 18.
"Seriously disabled" (Item 29H) means that the child became permanently unable to support himself/herself before reaching age 18. Furnish a statement from an
attending physician or other medical evidence which shows the nature and extent of the physical or mental impairment.
Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over age 18 is entitled to receive DIC benefits in his or her own right. A
veteran's child who is seriously disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.
Page 4
VA FORM 21P-534, OCT 2018
PART V - DEPENDENT CHILDREN (Complete ONLY if claiming benefits for a child(ren) of the veteran)
(Skip to Section VI if you are NOT claiming benefits for a child(ren) of the veteran) (Continued)
29B. DATE (month, day,
(Check all that apply)
29C. SOCIAL
29A. NAME OF CHILD
year) and PLACE OF
29I.
29H.
29J. CHILD
SECURITY
29G.
29D.
29E.
29F.
(First, middle initial, last name)
BIRTH
CHILD
SERIOUSLY
PREVIOUSLY
18-23 YEARS
NUMBER
BIOLOGICAL
ADOPTED
STEPCHILD
(city/state or country)
MARRIED
DISABLED
MARRIED
OLD (in school)
Tell us about the child(ren) listed in Item 29A that do not live with you in Items 30A through 30D.
30B. CHILD'S COMPLETE ADDRESS
30D. MONTHLY AMOUNT YOU
30A. NAME OF CHILD
30C. NAME OF PERSON THE CHILD
(Number and street or rural route, city or P.O., city,
CONTRIBUTE TO THE CHILD'S
(First, middle initial, last name)
LIVES WITH (If applicable)
State, ZIP Code and country)
SUPPORT
$
$
$
PART VI - HOUSEBOUND, IN A NURSING HOME OR REQUIRE AID AND ATTENDANCE
NOTE: If you are claiming aid and attendance allowance and/or housebound benefits because you need the regular assistance of another person, are
having severe visual problems, or are housebound and not in a nursing home, submit a statement from your doctor showing the extent of your disabilities.
If you are in a nursing home, attach a statement signed by an official of the nursing home showing the date you were admitted, the level of care you receive,
the amount you pay out-of-pocket for your care, and whether Medicaid covers all or part of your nursing home costs.
31. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
PROBLEMS, OR ARE CONFINED TO YOUR IMMEDIATE PREMISES?
(If "Yes," please complete and attach with this application VA Form 21-2680, Exam for Housebound Status or Permanent Need for
NO
YES
Regular Aid and Attendance. Please make sure every box is complete and signed by a Physician, Physician Assistance (PA),
Certified Nurse Practitioner (CNP), or Clinical Nurse Specialist (CNS))
32B. PROVIDE THE NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY
32A. ARE YOU NOW IN A NURSING HOME?
(If "Yes," answer Items 32B and 32C and submit a statement
YES
NO
from an official of the nursing home that tells us that you are a
patient in the nursing home because of a physical or mental
disability. The statement should include the monthly charge you
are paying out-of-pocket for your care)
32C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
32D. HAVE YOU APPLIED FOR MEDICAID?
(If "No," answer Item 32D)
YES
NO
YES
NO
PART VII - INCOME AND ASSETS
33A. HAVE YOU CLAIMED OR ARE YOU RECEIVING BENEFITS FROM THE SOCIAL SECURITY ADMINISTRATION ON YOUR OWN BEHALF OR ON BEHALF OF
A CHILD OR CHILDREN IN YOUR CUSTODY?
YES
NO
(If "Yes," answer Item 40B)
33B. IS SOCIAL SECURITY BASED ON YOUR OWN EMPLOYMENT?
YES
NO
34. HAS A SURVIVING SPOUSE OR CHILD FILED A CLAIM FOR COMPENSATION FROM THE OFFICE OF WORKER'S COMPENSATION PROGRAMS BASED
ON THE DEATH OF THE VETERAN?
YES
NO
35. HAS A COURT AWARDED DAMAGES BASED ON THE DEATH OF THE VETERAN OR IS A CLAIM OR LEGAL ACTION FOR DAMAGES PENDING?
YES
NO
36. HAVE YOU CLAIMED OR ARE YOU RECEIVING SURVIVOR BENEFIT PLAN (SBP) ANNUITY FROM A SERVICE DEPARTMENT BASED ON THE DEATH OF
THE VETERAN?
YES
NO
VA FORM 21P-534, OCT 2018
Page 5

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VA Form 21P-534 Instructions

The general instructions for the VA 21P-534 Form are provided on the first page of the document. You can detach them and keep them for future reference.

As defined by law, the amount of pension VA pays is based on the family income and assets, as well as on the number of dependent children. Your complete and correct information will be used to determine your eligibility for the benefits.

You can assign a VA accredited Veterans Service Organization, a VA accredited attorney/claims agent, or other service organization recognized by the Secretary of Veteran affairs to act as your official representative. If you wish to use a representative, you need to contact your local VA office and fill out the corresponding forms.

You can ask for a personal hearing during processing the claim or after receiving the VA decision if you believe the VA has made an error. Notify your local VA office and an authorized representative will schedule a time and place for the hearing.

How to Fill out VA Form 21P-534?

When completing the VA 21P-534, it is necessary to print all the answers clearly. All the required items must be filled out. If the answer is "unknown", "no", or "0", that should be indicated in the corresponding field.

Filing instructions are as follows:

  1. Part I. Claim Information. Provide information on the type of benefits you request, whether you and the veteran have filed any other claims, and your relationship to the veteran.
  2. Part II. Identifying Information. Provide personal information about yourself and the veteran.
  3. Part III. Veteran's Active Duty Service. Indicated all the required information for all periods of veteran service. If the veteran has never filed any claim with the VA, attach the original DD214 or its certified copy to this form. The original documents will be returned after processing.
  4. Part IV. Marital Information. If you request benefits as the surviving spouse, it is necessary to complete Items 22A - 28 providing complete information about your and the veteran union. Otherwise, skip to Part V.
  5. Part V. Dependent Children. Enter information about biological, adopted, and stepchildren of the veteran. If you are not claiming benefits for the veteran's children, move to Part VI.
  6. Part VI. Housebound. Complete this section if you request aid and benefits because of being housebound, in a nursing home, or requiring aid and attendance. Moreover, when you claim expenses for an assisted living facility or adult daycare it is necessary to complete VA aid and attendance form worksheets attached to this document.
  7. Parts VII and VIII. Income and Assets. Provide all relevant information.
  8. Part IX. Direct Deposit Information. Provide all the required information.
  9. Part X. Medical. Fill it out if you request unreimbursed medical expenses. Describe all medical, burial, and other unreimbursed expenses.
  10. Part XI. Signature. Sign and date the completed VA 21P-534.
  11. Part XII. Remarks. Provide any additional data.

Where to Mail VA Form 21P-534?

Mail the completed VA 21P-534 Form, as well as all the supporting documentation to the nearest regional VA office. The mailing addresses of all the VA offices can be found on the VA official website.

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