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12NOTICE TO BENEFICIARY/CLAIMANT REGARDING THE INFORMATION AND EVIDENCE NEEDED TO
SUPPORT A CLAIM FOR ADDITIONAL BENEFITS FOR A DEPENDENT OR TO REMOVE A
DEPENDENT FROM AN AWARD
Use this form and the attached application to:
• submit a claim for additional benefits for a dependent, or
• request removal of a dependent from your award.
The table below identifies the types of dependents for whom VA beneficiaries may be entitled to additional benefits.
T
If you are a …
hen you may be entitled to additional benefits for …
veteran entitled to disability compensation who has a
• a spouse,
combined disability rating of at least 30 percent
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school,
• children over age 18 that are permanently incapable of self-support, and/or
• dependent parents.
veteran entitled to Veterans Pension
• a spouse,
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school, and/or
• children over age 18 that are permanently incapable of self-support
•
surviving spouse entitled to survivors benefits
children under age 18,
•
children that are between the ages of 18 and 23 who are attending school, and/or
•
children over age 18 that are permanently incapable of self-support.
Exception: A surviving spouse entitled to Dependency and Indemnity Compensation (DIC) is
not entitled to additional benefits for children over age 18 that receive DIC in their own right.
TABLE OF CONTENTS
The table below provides a guide to the instructions and the application. The completion of certain sections of this application are
required. Be aware that you must complete Section I - Veteran/Claimant's Identification Information and Section X - Beneficiary/
Claimant's Certification and Signature. If these sections are not complete, we will not be able to process your claim for additional
benefits for dependents. Otherwise, complete the remaining sections that apply to you.
If you are …
Instructions
Application
claiming additional benefits for a spouse
Pages 3 and 4
Pages 7 and 8
claiming additional benefits for a child
Pages 4 - 5
Pages 8 and 9
reporting a divorce
Page 5
Page 10
reporting that a stepchild is no longer a member of your
household
Page 6
Page 10
reporting the death of a
Page 5
Page 10
• spouse
Page 6
• child
Page 6
• dependent parent
reporting the marriage of a child
Page 6
Page 10
reporting that a schoolchild over 18 has stopped attending school
Page 6
Page 11
claiming additional benefits for more than four children
Addendum - Page 12
CIRCUMSTANCES THAT REQUIRE ADDITIONAL FORMS
Under certain circumstances, other forms in addition to VA Form 21-686c, Application Request to Add and/or Remove Dependents,
must be provided when claiming additional benefits for a dependent. The table below describes those circumstances. All VA forms
are available at www.va.gov/vaforms.
Page 1
VA FORM 21-686c, SEP 2018
NOTICE TO BENEFICIARY/CLAIMANT REGARDING THE INFORMATION AND EVIDENCE NEEDED TO
SUPPORT A CLAIM FOR ADDITIONAL BENEFITS FOR A DEPENDENT OR TO REMOVE A
DEPENDENT FROM AN AWARD
Use this form and the attached application to:
• submit a claim for additional benefits for a dependent, or
• request removal of a dependent from your award.
The table below identifies the types of dependents for whom VA beneficiaries may be entitled to additional benefits.
T
If you are a …
hen you may be entitled to additional benefits for …
veteran entitled to disability compensation who has a
• a spouse,
combined disability rating of at least 30 percent
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school,
• children over age 18 that are permanently incapable of self-support, and/or
• dependent parents.
veteran entitled to Veterans Pension
• a spouse,
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school, and/or
• children over age 18 that are permanently incapable of self-support
•
surviving spouse entitled to survivors benefits
children under age 18,
•
children that are between the ages of 18 and 23 who are attending school, and/or
•
children over age 18 that are permanently incapable of self-support.
Exception: A surviving spouse entitled to Dependency and Indemnity Compensation (DIC) is
not entitled to additional benefits for children over age 18 that receive DIC in their own right.
TABLE OF CONTENTS
The table below provides a guide to the instructions and the application. The completion of certain sections of this application are
required. Be aware that you must complete Section I - Veteran/Claimant's Identification Information and Section X - Beneficiary/
Claimant's Certification and Signature. If these sections are not complete, we will not be able to process your claim for additional
benefits for dependents. Otherwise, complete the remaining sections that apply to you.
If you are …
Instructions
Application
claiming additional benefits for a spouse
Pages 3 and 4
Pages 7 and 8
claiming additional benefits for a child
Pages 4 - 5
Pages 8 and 9
reporting a divorce
Page 5
Page 10
reporting that a stepchild is no longer a member of your
household
Page 6
Page 10
reporting the death of a
Page 5
Page 10
• spouse
Page 6
• child
Page 6
• dependent parent
reporting the marriage of a child
Page 6
Page 10
reporting that a schoolchild over 18 has stopped attending school
Page 6
Page 11
claiming additional benefits for more than four children
Addendum - Page 12
CIRCUMSTANCES THAT REQUIRE ADDITIONAL FORMS
Under certain circumstances, other forms in addition to VA Form 21-686c, Application Request to Add and/or Remove Dependents,
must be provided when claiming additional benefits for a dependent. The table below describes those circumstances. All VA forms
are available at www.va.gov/vaforms.
Page 1
VA FORM 21-686c, SEP 2018
If ...
Then submit ...
•
VA Form 21-674, Request for Approval of School Attendance.
you are seeking additional benefits for a child or
children who are between the ages of 18 and 23
Note: Submit VA Form 21-686c in addition to VA Form 21-674 only if you
who are attending school
have never received additional benefits for the child or children.
submit VA Form 21P-0516-1, Improved Pension Eligibility Verification
• you are entitled to Veterans Pension (instead of
disability compensation based on service-
Report (Veteran With No Children), in addition to VA Form 21-686c.
connected disabilities), and
• you are seeking additional benefits for a spouse
only
• you are entitled to Veterans Pension
VA Form 21P-0517-1, Improved Pension Eligibility Verification Report
(Veteran With Children), in addition to VA Form 21-686c.
• you are seeking additional benefits for a child or
children (with or without a spouse), and
• the child or children are under the age of 23 or
permanently incapable of self-support
• you are entitled to Survivors Pension,(instead of
VA Form 21P-0519s-1, Improved Pension Eligibility Verification Report
(Surviving Spouse With Children), in addition to VA Form 21-686c.
DIC based on a veteran's service-connected death)
and
• you are seeking additional benefits for a child or
children that are either under the age of 23 or
incapable of self-support.
• you are a veteran entitled to disability
VA Form 21P-509, Statement of Dependency of Parent(s).
compensation (based on service-connected
Note: There is no need to submit VA Form 21-686c when filing a claim for
disabilities), and
• you are seeking additional benefits for a
additional benefits for a dependent parent or parents.
dependent parent or parents.
• you are a veteran entitled to disability
VA Form 21-2680, Examination for Housebound Status or Permanent Need
for Regular Aid and Attendance, or if your spouse resides in a nursing home,
compensation, and
• you are seeking additional benefits for a spouse
use VA Form 21-0779, Request for Nursing Home Information in
Connection with Claim for Aid and Attendance.
who requires aid and attendance
Note: Submit VA Form 21-686c in addition to one of the forms referenced
above only if you have never received additional benefits for your spouse.
•
VA Form 21-4170, Statement of Marital Relationship, and
you are a veteran seeking additional benefits for
VA Form 21P-4171, Supporting Statement Regarding Marriage.
a spouse based on common-law marriage
Note: The above referenced forms must be submitted in addition to
VA Form 21-686c.
HOW TO SUBMIT
May I apply electronically? You may apply for additional benefits for dependents and/or request removal of dependents online
through eBenefits at www.ebenefits.va.gov. If you do not have an account, you must create one. Once you have logged into your
account, select the "Add or Remove Dependent" hyperlink on the "Apply for Benefits" page. Once you have electronically submitted
the form, you will be able to track your claim status using eBenefits.
NOTE: You may wish to contact an accredited veteran service officer (VSO) to assist you with your application. You may locate a list of
https://www.va.gov/vso/
VSO's at
.
WHERE TO SEND INFORMATION AND EVIDENCE
MAIL TO:
FAX TO:
ONLINE:
Department of Veterans Affairs
844-531-7818 (toll free)
www.ebenefits.gov
Evidence Intake Center
248-524-4260 (foreign claims)
PO Box 4444 Janesville, WI 53547-4444
Page 2
VA FORM 21-686c, SEP 2018
IMPORTANT: Applicants are required to provide their Social Security number (SSN), unless a SSN has not been assigned. Use Section
IX, Item 25, Remarks, to explain why a SSN has not been assigned.
TO ADD A SPOUSE TO A VETERAN'S AWARD:
Marriage by Ceremony
VA will require additional evidence* to establish a spouse; if
•
you do not reside within a state, territory, or other possession of the United States,
•
your entries on the application conflict with other information you provided, and the discrepancies
cannot be resolved through contact with you or a review of other information of record
•
information of record raises questions regarding the validity of the marriage, or
•
there is an indication of fraud or misrepresentation.
*Additional Evidence:
•
Primary evidence of a marriage consists of a copy or abstract of the public record of a marriage, or a copy of the church
record of a marriage, containing sufficient data to identify the
• parties involved,
• date (month, day, and year) and place (city and state, county and state, or city and country) of the marriage, and
• number of prior marriages for each spouse, if not shown on the official record.
•
If primary evidence of a marriage is unavailable, a marriage may still be established by submission of the following
evidence in the order of preference shown below;
• an official report from your branch of service regarding a marriage that occurred while you were in service,
• an affidavit of the clergyman or magistrate who officiated in the marriage ceremony,
• a certified copy of the original certificate of marriage,
• affidavits or certified statements signed by two or more witnesses that attended the marriage ceremony, or
• any other secondary evidence that reasonably supports the assertion that a valid marriage occurred.
Note: The process to establish a same sex or transgender marriage is no different than the process to establish a marriage between
of the opposite sex.
Establishing a Common-Law Marriage
In some states it is possible to contract a marriage without a ceremony and without registration of the marriage. This type of marriage is
referred to as a common-law marriage.
VA may recognize a common-law marriage that was considered valid in the state in which it took place. A common law marriage
generally requires an agreement between the parties to be married, cohabitation, and holding themselves out to the public as married.
Evidence that must be submitted to claim a common-law marriage:
•
VA Form 21-4170 completed by the veteran
•
VA Form 21-4170 completed by the veteran's spouse in the common-law marriage
•
Two VA Forms 21P-4171, each completed by two different persons that can provide their personal observations
about the parties to the common-law marriage and the relationship that exists/existed between them, and
•
Copies of the birth certificates of any children born of the common-law marriage.
Tribal Ceremony
VA may recognize marriages performed in accordance with tribal custom.
To establish a tribal marriage, a claimant must provide all of the following items:
• Affidavits from the parties married by tribal custom that include the name of the tribe, date (month, day, and year) of marriage,
place (city and state, county and state, or city and country) where the marriage ceremony occurred, and name/mailing address of
the person who performed the ceremony.
• Affidavits from at least two people who were present at the time the tribal marriage ceremony took place. The affidavits must
include the name of the tribe, date (month, day, and year) of marriage, place (city and state, county and state, or city and country)
where the marriage ceremony occurred, and name/mailing address of the person who performed the ceremony.
• Affidavit from the person who performed the ceremony, showing the date (month, day, and year) and place (city and state,
county and state, or city and country) where the marriage ceremony occurred, and that person's authority for conducting the
ceremony.
Page 3
VA FORM 21-686c, SEP 2018
Proxy Marriage
A proxy marriage is a wedding in which one or both of the individuals being united are not physically present, and are instead
represented by other persons. If both partners are absent, a double proxy wedding occurs.
Marriage by proxy typically occurs when a couple wishes to marry, but one or both partners cannot attend for reasons such as military
service, imprisonment, or travel restrictions; or when a couple lives in a jurisdiction in which they cannot legally marry.
All documents/certificates issued in connection with a claimed proxy marriage must be provided to establish a proxy marriage for VA
purposes.
Note: The validity of a proxy marriage is dependent upon the law in effect at the location in which the proxy marriage was performed.
Spousal Aid & Attendance (A&A)
• VA may pay additional benefits to a Veteran for a spouse with severe medical need/disability (ies). To claim the additional
benefits, a
• Veteran must complete a VA Form 21-2680 and submit medical evidence showing his or her spouse
• is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes or concentric contraction of the visual
field to 5 degrees or less; or
• is a patient in a nursing home because of mental or physical incapacity (by completing VA Form 21-0779); or
• requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding,
dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her
daily environment.
TO ADD A CHILD TO A BENEFICIARY/CLAIMANT'S AWARD:
Unmarried Child
A person must be unmarried in order to be considered a child for VA purposes.
VA may continue paying additional benefits for an unmarried child
• until the child reaches age
o 18, or
o 23, if the child is attending an approved school, or
• indefinitely if the child becomes permanently incapable of self-support before his/her 18
birthday.
th
VA will require a copy of the child's birth certificate; if
• you do not reside within a state, territory or other possession of the United States,
• your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through
contact with you or a review of other information of record, or
• there is an indication of fraud or misrepresentation.
School-Age Child
You must complete and submit VA Form 21-674 to claim additional benefits for a child who is
• between the ages of 18 and 23, and
• attending school.
Note:
• Claimants with more than one school-age child must complete a separate VA Form 21-674 for each child.
• VA Form 21-674 is used to report
o school attendance,
o a change in the educational facility a child is attending, and/or
o a change in the date a school-age child plans to stop attending school.
Stepchild
VA will ask you to provide a copy of your stepchild's birth certificate, showing the names of both parents, before it will add the
stepchild; if
• you do not reside within a state, territory, or other possession of the United States,
• your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through
contact with you or a review of other information of record.
Page 4
VA FORM 21-686c, SEP 2018
• information of record raises questions regarding the validity of the marriage of the stepchild's biological or adoptive parent to
the veteran, or
• there is an indication of fraud or misrepresentation.
Provide a copy of the decree of adoption or adoptive placement agreement if the veteran's spouse is the adoptive parent of the
stepchild.
Note:
• VA may pay benefits to or for a stepchild only if the stepchild is (or was at the time of the veteran's death, if the veteran is
deceased) a member of the veteran's household.
• If the veteran and stepchild do not reside together (or were not residing together when the veteran died, if the veteran is
deceased), the stepchild remains a member of the veteran's household if
• they live (or lived, if the veteran is deceased) apart for medical reasons, to attend school, or to fulfill a military service
obligation, or
• the veteran provides (or provided, if the veteran is deceased) at least half of the stepchild's support.
Adopted Child
A claim for additional benefits for an adopted child must include a copy of the
• final decree of adoption,
• adoptive placement agreement,
• interlocutory decree of adoptions, or
• revised birth certificate.
Note: VA cannot pay additional benefits for a grandchild or foster child unless the claimant submits evidence (referenced above)
showing the veteran adopted the grand/foster child.
Child Incapable of Self-Support
VA may pay additional benefits for a child beyond his/her 23
birthday if VA determines the child became permanently incapable of
rd
self-support before his/her 18
birthday.
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A claim for additional benefits for a child who is incapable of self-support must include
• medical evidence showing a permanent mental or physical disability existed before his/her 18
birthday, and
th
• a statement from an attending physician showing the nature and extent of the child's physical or mental impairment.
REMOVAL OF A SPOUSE FROM A VETERAN'S AWARD:
Divorce or Death of a Spouse
VA must remove a spouse from a veteran's award when the spouse dies or divorces/annuls the marriage to the veteran.
Note:
• Veterans in receipt of disability compensation are not required to report to VA a separation or estrangement from their spouse,
as it will have no effect on their award.
• Veterans remain entitled to additional benefits for a stepchild after divorcing the stepchild's biological or adoptive parent, as
long as the veteran provides at least half of the stepchild's support.
VA FORM 21-686c, SEP 2018
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