VA Form 21P-534EZ "Application for Dic, Survivors Pension, and/or Accrued Benefits"

What Is VA Form 21P-534EZ?

VA Form 21P-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits is a document used to request Dependency and Indemnity Compensation (DIC), death pension, and accrued benefits under the Fully Developed Claim Program (FDC). The information provided to the Department of Veterans Affairs (VA) via this form is used for determination of allowance to the compensation or benefits.

The latest version of the form - formerly known as VA Form 21-534EZ - was released by the VA in October 2018. The most recent fillable VA Form 21P-534EZ is available for download below or can be found on the VA website.

The document has two related forms:

The first form is used by the surviving spouse or child to apply for dependency and indemnity compensations, death pension, and accrued benefits, including death compensation if applicable. The second form is filled out to request service-connected death benefits and compensations only.

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NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
DEPENDENCY AND INDEMNITY COMPENSATION, SURVIVORS PENSION, AND/OR
ACCRUED BENEFITS
(This notice is applicable to survivors claims for: Survivors Pension • Dependency Indemnity Compensation (DIC) •
DIC under 38 U.S.C. 1151 • Increased Survivor Benefits Based on Need for Special Monthly Pension • Accrued Benefits •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for DIC, Survivors Pension, and/or Accrued Benefits.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and
there is no risk to participate! To participate in the FDC Program if you are making a claim for DIC, Survivors Pension, and/or
Accrued Benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans disability compensation or related compensation benefits, use VA Form 21-526EZ, Application for Disability Compensation
and Related Compensation Benefits. If you are claiming veterans Pension benefits, use VA Form 21P-527EZ, Application for
Veterans Pension. VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for DIC, Survivors Pension, and/or Accrued Benefits)
1. Submit your claim on a signed and completed VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or
Accrued Benefits (Attached).
2. Submit simultaneously with your claim:
A copy of the veteran's Death Certificate (unless he or she died on active duty); AND
. .
If claiming Survivors Pension:
All necessary income and asset information; AND
If claiming Survivors Pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a) nursing home,
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and
Attendance
If claiming DIC:
.
All, if any, of the veteran's relevant, private medical treatment records and an identification of any
of the veteran's treatment records available at a Federal facility, such as a VA medical center, that supports
.
your claim that a service-connected disability caused the veteran's death or the veteran's death was caused by the VA.
.
Any and all Service Treatment and Personnel Records in the custody of the veteran's Guard or Reserve Unit(s).
If claiming DIC as the parent of the veteran, all necessary income information and, if claiming benefits as the
foster parent of the veteran, a completed VA Form 21P-524, Statement of Person Claiming to Have Stood in
.
Relation of Parent.
If claiming DIC with special monthly DIC, a completed VA Form 21-2680, Examination for Housebound
Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home) a completed VA Form
21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Requirements for Certain Claimants:
.
If claiming benefits as the surviving spouse of the veteran, a copy of your marriage certificate showing
your marriage to the veteran, or if claiming benefits for a child or biological/adoptive parent of the
veteran, a copy of the birth certificate or court record of adoption showing relation to the veteran.
.
If claiming benefits for a child of the veteran between the ages of 18 and 23, a completed
.
VA Form 21-674, Request for Approval of School Attendance.
If claiming benefits for a seriously disabled child of the veteran, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities showing the child was incapable of self-support before age 18.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
Page 1
VA FORM
21P-534EZ
SUPERSEDES VA FORM 21-534EZ, JUN 2018,
OCT 2018
WHICH WILL NOT BE USED.
NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
DEPENDENCY AND INDEMNITY COMPENSATION, SURVIVORS PENSION, AND/OR
ACCRUED BENEFITS
(This notice is applicable to survivors claims for: Survivors Pension • Dependency Indemnity Compensation (DIC) •
DIC under 38 U.S.C. 1151 • Increased Survivor Benefits Based on Need for Special Monthly Pension • Accrued Benefits •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for DIC, Survivors Pension, and/or Accrued Benefits.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and
there is no risk to participate! To participate in the FDC Program if you are making a claim for DIC, Survivors Pension, and/or
Accrued Benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans disability compensation or related compensation benefits, use VA Form 21-526EZ, Application for Disability Compensation
and Related Compensation Benefits. If you are claiming veterans Pension benefits, use VA Form 21P-527EZ, Application for
Veterans Pension. VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for DIC, Survivors Pension, and/or Accrued Benefits)
1. Submit your claim on a signed and completed VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or
Accrued Benefits (Attached).
2. Submit simultaneously with your claim:
A copy of the veteran's Death Certificate (unless he or she died on active duty); AND
. .
If claiming Survivors Pension:
All necessary income and asset information; AND
If claiming Survivors Pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a) nursing home,
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and
Attendance
If claiming DIC:
.
All, if any, of the veteran's relevant, private medical treatment records and an identification of any
of the veteran's treatment records available at a Federal facility, such as a VA medical center, that supports
.
your claim that a service-connected disability caused the veteran's death or the veteran's death was caused by the VA.
.
Any and all Service Treatment and Personnel Records in the custody of the veteran's Guard or Reserve Unit(s).
If claiming DIC as the parent of the veteran, all necessary income information and, if claiming benefits as the
foster parent of the veteran, a completed VA Form 21P-524, Statement of Person Claiming to Have Stood in
.
Relation of Parent.
If claiming DIC with special monthly DIC, a completed VA Form 21-2680, Examination for Housebound
Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home) a completed VA Form
21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Requirements for Certain Claimants:
.
If claiming benefits as the surviving spouse of the veteran, a copy of your marriage certificate showing
your marriage to the veteran, or if claiming benefits for a child or biological/adoptive parent of the
veteran, a copy of the birth certificate or court record of adoption showing relation to the veteran.
.
If claiming benefits for a child of the veteran between the ages of 18 and 23, a completed
.
VA Form 21-674, Request for Approval of School Attendance.
If claiming benefits for a seriously disabled child of the veteran, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities showing the child was incapable of self-support before age 18.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
Page 1
VA FORM
21P-534EZ
SUPERSEDES VA FORM 21-534EZ, JUN 2018,
OCT 2018
WHICH WILL NOT BE USED.
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are
entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your
claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard
Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional
Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim
Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession. If your claim involves a disability the veteran had before entering service and that was made worse
by service, please provide any information or evidence in your possession regarding the health condition that existed before the
veteran's entry into service.
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
You must:
• Submit your claim in accordance with the
• If you know of evidence not in your possession and want
"FDC Criteria" (see page 1)
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
FDC Program (Optional Expedited Process)
Standard Claim Process
VA will:
VA will:
• Retrieve relevant records from a Federal facility, such as
• Retrieve relevant records from a Federal facility that you
a VA medical center, that you adequately identify and
adequately identify and authorize VA to obtain
authorize VA to obtain
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from state or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers
WHEN YOU SHOULD SEND WHAT WE NEED
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
We strongly encourage you to:
• Send the information and evidence simultaneously with
• Send any information or evidence as soon as you can
your claim
If you submit additional information or evidence after you
You have up to one year from the date we receive the claim to
submit your "fully developed" claim, then VA will remove the
submit the information and evidence necessary to support your
claim from the FDC Program expedited process and process
claim. If we decide the claim before one year from the date we
it in the Standard Claim process. If we decide your claim before
receive the claim, you will still have the remainder of the
one year from the date we receive the claim, you will still have
one year period to submit additional information or evidence
the remainder of the one-year period to submit additional
necessary to support the claim.
information or evidence necessary to support the claim.
WHERE TO SEND INFORMATION AND EVIDENCE
Mail or take your application and any evidence in support of your claim to the closest VA regional office. VA regional office
addresses are available on the Internet at www.va.gov/directory.
Page 2
VA FORM 21P-534EZ, OCT 2018
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
If you are claiming...
See the evidence table titled...
Needs-based benefits based on the veteran's wartime service.
Survivors Pension
• The veteran's death was related to his or her service (DIC), OR
Dependency and Indemnity Compensation (DIC)
• DIC because the veteran was receiving or entitled to receive
benefits for a service-connected disability rated totally
disabling.
The veteran's death was a result of VA medical treatment,
DIC under 38 U.S.C. 1151
vocational rehabilitation, or compensated work therapy.
DIC and it was previously denied by VA.
Reopened DIC
Increased Survivor Benefits Based on Special Monthly Pension
Special Monthly Pension.
You are entitled to the benefits that were due to the veteran at
Accrued Benefits
the time of the veteran's death.
You are eligible to benefits because a child of the veteran is
Child Incapable of self-support
severely disabled.
EVIDENCE TABLES
Survivors Pension
To support your claim for Survivors Pension, the evidence must show:
1. The veteran met certain minimum active service requirements during a period of war.
Generally, those requirements are:
• 90 days of consecutive service, at least one day of which was during a period of war; OR
• 90 days of combined service during at least one period of war;
(Note : If the veteran's service began after September 7, 1980, additional length-of-service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligations.)
OR any length of active service during a period of war when:
• At the time of death, the veteran was receiving (or entitled to receive) VA disability compensation or
retirement pay for a service-connected disability; OR
• The veteran was discharged from active service due to a service-connected disability.
2. Your income and assets do not exceed certain requirements.
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
encumbrances 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.
Dependency and Indemnity Compensation (DIC)
To support a claim for Dependency and Indemnity Compensation (DIC) based on a service-connected disability:
• The veteran died while on active service; OR
• The veteran had a service-connected disability(ies) that was either the principal or contributory cause of
the veteran's death; OR
• The veteran died from 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.
To support a claim for DIC based on a disability that was not service-connected or for which the veteran did not file
a claim during his or her lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active service, or an event in service that caused an injury
or disease; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by
medical evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in service. This may
be shown by medical records or medical opinion or, in certain cases, by lay evidence.
Page 3
VA FORM 21P-534EZ, OCT 2018
EVIDENCE TABLES (Continued)
Dependency and Indemnity Compensation (DIC) (Continued)
To support your claim for DIC based upon the service person's active duty for training, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty, and
the disease or injury caused or contributed to the service person's death.
If VA granted service connection for a disease or injury during the service person's lifetime, evidence that the service-connected
disease or injury caused or contributed to the service person's death may satisfy this requirement.
To support a claim for DIC based on a disability that was not service-connected or for which the service person
did not file a claim during his or her lifetime, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by medical
evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the principal or contributory cause of death and the disability due to injury or disease, incurred in
the line of duty. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.
To support your claim for DIC based upon the service person's inactive duty training, the evidence must show:
• The service person died during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute
myocardial infarction, cardiac arrest, or cerebrovascular accident during such training; OR
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty,
or acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; and that
injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's
death
If VA granted service connection for an injury, acute myocardial infarction, or cerebrovascular accident during the service person's
lifetime, evidence that the service-connected condition caused or contributed to the service person's death may satisfy this
requirement.
To support a claim for DIC based on a disability that was not service-connected or for which the service person did not
file a claim during his or her lifetime, the evidence must show:
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or
acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; AND
• The injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service
person's death
DIC under 38 U.S.C. 1151:
In order to support your claim for DIC under 38 U.S.C. 1151, the evidence must show:
• The deceased veteran died as a result of undergoing VA hospitalization, medical or surgical treatment,
examination, or training; AND
• The death was:
• the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment; OR
• the direct result of an event that was not a reasonably expected result or complication of the VA care or treatment; OR
• the direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy
program
Reopened DIC:
In order to reopen a claim previously denied by VA, we need new and material evidence. New and material evidence must raise
a reasonable possibility of substantiating your claim. The evidence cannot simply be repetitive or cumulative of the evidence we
had when we previously decided your claim. VA will make reasonable efforts to help you obtain currently existing evidence.
However, we cannot provide a medical examination or obtain a medical opinion until your claim is successfully reopened.
• To qualify as new, the evidence must currently exist and be submitted to VA for the first time
• In order to be considered material, the additional existing evidence must pertain to the reason
your claim was previously denied
Page 4
VA FORM 21P-534EZ, OCT 2018
EVIDENCE TABLES (Continued)
Increased Survivor Benefits Based on Special Monthly Pension
In order to support your claim for increased survivor benefits based on the need for aid and attendance, the evidence must
show:
• you have corrected vision of 5/200 or less in both eyes; OR
• you have concentric contraction of the visual field to 5 degrees; OR
• you are a patient in a nursing home due to mental or physical incapacity; OR
• you require 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
• you are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed
course of convalescence or treatment (38 Code of Federal Regulations 3.352(a)); OR
In order to support your claim for increased benefits based on being housebound, the evidence must show:
• you are substantially confined to your immediate premises because of permanent disability
Accrued Benefits:
To support a claim for accrued benefits, the evidence must show:
• Benefits were due the veteran based on existing ratings, decisions, or evidence in VA's possession at the
time of death, but the benefits were not paid before the veteran's death; AND
• You are the surviving spouse, child, or dependent parent of the deceased veteran
VA pays accrued benefits in the following order of priority:
1. Spouse
2. Children of the veteran (in equal shares)
3. Dependent parents (in equal shares)
Child Incapable of Self-Support:
To support a claim for benefits based on a veteran's child being incapable of self-support, the evidence must show that
the child, before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.
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. § 103(c)). Additional guidance on when VA recognizes marriages is
available at http://www.va.gov/opa/marriage/.
HOW VA DETERMINES THE EFFECTIVE DATE
If we grant a claim for Survivors benefits, the beginning date of your entitlement will generally be the date we received your claim.
However, if VA receives your claim within one year after the date of the veteran's death, entitlement will be from the first day of the
month in which the veteran died.
The veteran's death certificate is evidence relevant to determining the effective date of any benefits we award.
Special monthly pension may be available for a veteran's surviving spouse and/or parents who are unable to perform certain activities
of daily living, are a patient in a nursing home, or are substantially confined to their immediate premises. Special monthly pension
may be effective from the date medical evidence first shows entitlement.
For more information on the FDC Program, visit our web site at
http://benefits.va.gov/transformation/fastclaims/
For more
information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.com/, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 711.
VA forms are available at www.va.gov/vaforms.
Page 5
VA FORM 21P-534EZ, OCT 2018
ADVERTISEMENT

Help with VA Form 21P-534EZ

If you need help with completing the form or just want more information on the VA benefits, you can contact the VA representative online or call a toll-free number at 1-800-827-1000.

Besides, you can have an authorized representative to help you with completing the form, collecting all required evidence, and filing a claim. This representative can be an accredited attorney, a claim agent, or a Veterans Service Officer. To set up a person acting on your behalf, you need to inform the VA about that first using eBenefits or filling out and mailing one of the following documents:

  • To have a Veterans Service Officer as a representative, it is necessary to file and submit a copy of VA Form 21-22;
  • To set up a claims agent or attorney as an official representative, VA Form 21-22A should be submitted.

How to Fill out VA Form 21P-534EZ?

VA Form 21P-534EZ instructions are as follows:

  1. Section I must be completed by all the applicants and contain your and veteran's personal data.
  2. Items 1 through 9 require the complete information about the veteran, including full name, sex, Social Security number (SSN), dates of birth and death, service number, VA file number (if the veteran, surviving spouse, child, or parent has ever filed a claim with VA), and the information if the veteran died while on active duty.
  3. In Items 10 through 16B, you should indicate your personal information, including name, relationship to the veteran, SSN, date of birth, if you are a veteran too, mail & e-mail addresses, and phone numbers.
  4. You have to specify the claiming benefits in Item 17.
  5. You should complete Section II only if the veteran at the time of death was not receiving any compensation or pension benefits. This part requires full information about the veteran's service.
  6. If you are claiming benefits as the surviving spouse of the veteran, Section III should be completed. Otherwise, it is required to skip this part.
  7. When filling out Section III, you need to enlist all your marriages, and the marriages of the veteran and enter all the details demanded.
  8. Section IV must be filled out only if you request benefits for the veteran's children (including biological, adopted, and stepchildren).
  9. Section V is to be filled out if you apply for benefits as the parent of the veteran, and should contain the information about your marital status, the details on your spouse (if any), and if the veteran was a member of your household or under your parental control.
  10. If you claim DIC, you should complete Section VI. It requires specification of DIC you are claiming and a full list of the VA medical centers the veteran was treated in pertaining to this claim, as well as the dates of treatments.
  11. Section VII should be completed if you request special benefits due to health problems that require the regular assistance or due to your being in a nursing home.
  12. If you request survivors pension or parents DIC, you must complete Section VIII. Otherwise, it should be skipped.
  13. Section IX requires information about medical, burial, educational, or vocational expenses. If you claim the expenses for in-home care or assisted living, you need to complete the corresponding worksheet on pages 12-13.
  14. You must indicate direct deposit data in Section X.
  15. If you do not want your application to be considered under the FDC Program, it should be indicated in Item 49, Section XI.

To be valid, VA 21P-534EZ requires your signature and the date. If you have signed using an "X", the names and signatures of two witnesses should be provided in Section XII.

Where to Mail VA Form 21P-534EZ?

After completing, you should mail or take the form - as well as all the supporting evidence - to the nearest VA regional office. All the addresses of the VA offices can be found at the VA official website.