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

What Is VA Form 21-534?

VA Form 21-534, Application for Dependency and Indemnity Compensation, Death Pension and Accrued Benefits a Surviving Spouse or Child (Including Death Compensation if Applicable) was used to apply for the Department of Veterans Affairs (VA) benefits or any money the VA owed to veterans that had not been paid prior to their death. The applicant could be a surviving spouse or child.

At present, VA 21-534 is obsolete and the VA Form 21P-534 is in use instead. The latest known version of the form was released in March 2009 and is available below for reference.

ADVERTISEMENT
GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION AND ACCRUED BENEFITS BY A
SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21-534
Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
2. Death pension may be payable when:
If you have any questions about this form, how to fill it out, or
the death of a veteran with wartime service is
about VA benefits, contact your nearest VA regional office.
not due to service, and
You can locate the address of the nearest regional office in
income is within applicable limits.
your telephone book blue pages under "United States
VA pays pension based on the amount of family income and
Government, Veterans" or call 1-800-827-1000 (Hearing Impaired
the number of dependent children. This is based on law. VA
TDD line 1-800-829-4833). You may also contact VA by Internet
must include as income all sources that Federal law specifies.
at https://iris.va.gov .
If there is no surviving spouse, pension may be payable on
behalf of a child or children.
B. What is the purpose of VA Form 21-534?
Unless a claim for dependency and indemnity compensation
Use VA Form 21-534 to apply for:
or death pension is filed within one year from the date of the
VA benefits you may be entitled to receive as a
veteran's death, that benefit is not payable from a date earlier
surviving spouse or child of a deceased veteran, and
than the date the claim is received in the VA.
any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).
If it is determined that you are entitled to DIC and death
pension, we will pay you whichever benefit entitles you to the
If you apply for any one of these benefits, the law requires that
most money. Benefit rates and income limits are frequently
we also consider you for the others.
changed, so it is not possible to keep this information current
in these instructions.
You can find out what the current
C. What is the purpose of the attached SSA-24 form?
income limitations and rates of benefits are by contacting your
nearest VA regional office.
You can apply for Social Security (SS) benefits by using the
SSA-24 form attached to this VA Form (see pages 9
E. How do I apply for aid and attendance allowance and/or
and 10). You don't have to apply if you don't want to or have
housebound benefits?
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
VA may pay a higher rate of DIC or pension to a surviving
for you. They will then contact you.
spouse who is blind, a patient in a nursing home, otherwise
needs regular aid and attendance, or who is permanently
confined to his or her home because of a disability. If you
D. What are dependency and indemnity compensation (DIC)
wish to apply for this benefit, check "Yes" for Item 31.
and death pension benefits, and how does VA decide what I
F. How do I complete my application?
will or will not receive?
Print all answers clearly. If an answer is "none" or "0," write
1. Dependency and indemnity compensation may be payable
that. Your answer to every question is important to help us
when:
complete your claim. If you do not know the answer, write
"unknown." For additional space, use Item 48, "Remarks, " or
a veteran's death occurred in service, or
attach a separate sheet, indicating the item number to which
a veteran dies of a service-connected disability, or
the answers apply.
Make sure you sign and date this
in certain circumstances if a veteran rated totally
application (Items 44 and 45).
disabled from service-connected disability dies from
non-service-connected conditions.
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.
21-534
VA FORM
SUPERSEDES VA FORM 21-534, JUN 2005,
General Instructions
PAGE 1
MAR 2009
WHICH WILL NOT BE USED.
GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION AND ACCRUED BENEFITS BY A
SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21-534
Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
2. Death pension may be payable when:
If you have any questions about this form, how to fill it out, or
the death of a veteran with wartime service is
about VA benefits, contact your nearest VA regional office.
not due to service, and
You can locate the address of the nearest regional office in
income is within applicable limits.
your telephone book blue pages under "United States
VA pays pension based on the amount of family income and
Government, Veterans" or call 1-800-827-1000 (Hearing Impaired
the number of dependent children. This is based on law. VA
TDD line 1-800-829-4833). You may also contact VA by Internet
must include as income all sources that Federal law specifies.
at https://iris.va.gov .
If there is no surviving spouse, pension may be payable on
behalf of a child or children.
B. What is the purpose of VA Form 21-534?
Unless a claim for dependency and indemnity compensation
Use VA Form 21-534 to apply for:
or death pension is filed within one year from the date of the
VA benefits you may be entitled to receive as a
veteran's death, that benefit is not payable from a date earlier
surviving spouse or child of a deceased veteran, and
than the date the claim is received in the VA.
any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).
If it is determined that you are entitled to DIC and death
pension, we will pay you whichever benefit entitles you to the
If you apply for any one of these benefits, the law requires that
most money. Benefit rates and income limits are frequently
we also consider you for the others.
changed, so it is not possible to keep this information current
in these instructions.
You can find out what the current
C. What is the purpose of the attached SSA-24 form?
income limitations and rates of benefits are by contacting your
nearest VA regional office.
You can apply for Social Security (SS) benefits by using the
SSA-24 form attached to this VA Form (see pages 9
E. How do I apply for aid and attendance allowance and/or
and 10). You don't have to apply if you don't want to or have
housebound benefits?
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
VA may pay a higher rate of DIC or pension to a surviving
for you. They will then contact you.
spouse who is blind, a patient in a nursing home, otherwise
needs regular aid and attendance, or who is permanently
confined to his or her home because of a disability. If you
D. What are dependency and indemnity compensation (DIC)
wish to apply for this benefit, check "Yes" for Item 31.
and death pension benefits, and how does VA decide what I
F. How do I complete my application?
will or will not receive?
Print all answers clearly. If an answer is "none" or "0," write
1. Dependency and indemnity compensation may be payable
that. Your answer to every question is important to help us
when:
complete your claim. If you do not know the answer, write
"unknown." For additional space, use Item 48, "Remarks, " or
a veteran's death occurred in service, or
attach a separate sheet, indicating the item number to which
a veteran dies of a service-connected disability, or
the answers apply.
Make sure you sign and date this
in certain circumstances if a veteran rated totally
application (Items 44 and 45).
disabled from service-connected disability dies from
non-service-connected conditions.
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.
21-534
VA FORM
SUPERSEDES VA FORM 21-534, JUN 2005,
General Instructions
PAGE 1
MAR 2009
WHICH WILL NOT BE USED.
G. What do I do when I have completed my application?
VA Form 21-22, Appointment of Veterans Service Organization
as Claimant's Representative, or VA Form 22A, Appointment of
Individual as Claimant's Representative. You may also
When you have completed this application mail it or take it to
download these forms at www.va.gov/vaforms. If you have
a VA regional office.
Be sure to attach any materials that
already designated a representative, no further action is required
support and explain your claim. Also, make a photocopy of
on your part.
your application and everything that you submit to VA before
mailing it.
I. What if I believe that VA has made an error in processing
or deciding my benefits?
H. How can I assign someone to act as my representative?
You can ask for a personal hearing at any time during the
A representative can be an accredited member of an accredited
processing of your claim. That means you can ask for the
organization or other service organization that the Secretary of
hearing while VA is processing your claim or after VA has
Veterans Affairs recognizes, an agent recognized by VA, or a
made a decision. You should contact the nearest VA office
licensed lawyer.
Agents and attorneys can charge you for
and tell them that you want a personal hearing on your case.
services that you get from them only after the Board of
Someone in the local VA office will arrange a time and place
Veteran's Appeals (BVA) gives you their final decision about
for your hearing. At this hearing, you can bring witnesses. VA
your application. That means you can use an attorney during
will record whatever you and your witnesses say during the
any stage of your application for benefits. However, the agent
hearing and include it in the official record. VA will furnish
or attorney cannot charge your for services unless you are
the hearing room and officials, and prepare a transcript of the
trying to resolve a dispute with VA after BVA has made a
hearing. VA cannot pay your expenses or the expenses of
decision about your claim.
anyone you want to bring with you to the hearing.
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:
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, 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). The VA will l 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information
on
where
to
send
comments
or
suggestions
about
this
form.
VA FORM 21-534, MAR 2009
General Instructions
PAGE 2
OMB Approved No. 2900-0004
Respondent Burden: 1 hour 15 minutes
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
Application for Dependency and Indemnity Compensation, Death Pension and Accrued
Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable)
VA Form 21-534
Please read the attached "General Instructions" before you fill out this form.
1. Did the veteran ever file a claim with VA?
2. What is the VA file number?
SECTION I
NO
(If "Yes," answer Item 2)
YES
Tell us what you
3.
Has the surviving spouse or child ever filed a
4. What is the VA file number?
are applying for
claim with VA?
and what you and
(If "Yes," answer Items 4
YES
NO
the deceased
through 6)
veteran have
5. What is the name of the person on whose service the claim was filed?
applied for
First
Middle
Last
6. What is your relationship to that person?
7. Are you claiming service connection for cause of death?
YES
NO
8. What is the veteran's name?
SECTION II
First
Middle
Last
Suffix (If applicable)
Tell us
9. What is the veteran's Social Security number?
10a. Did the veteran serve under another name?
about you
YES
NO
and the
(If "Yes," answer Item 10b)
deceased
veteran
10b.
Please list the other name(s) the veteran
11. What is the veteran's date of birth?
served under:
mo day
yr
12. What is the veteran's date of death?
13. Was the veteran a former prisoner of war?
Attach a copy of the
death certificate
YES
NO
unless the veteran
mo day
yr
died in active service
14. What is your name? (First, Middle, Last Name)
15. What is your relationship to the veteran?
of the Army, Navy,
(check one)
Air Force, Marine Corps,
or Coast Guard, or in a
Surviving Spouse
Child
U.S. government
16. What is your address?
institution.
Street address, Rural Route, or P.O. Box
Apt. number
City
State
ZIP Code
Country
17. What are your telephone numbers?
18. What is your e-mail address?
(Include Area Code)
Daytime
Evening
19. What is your Social Security number?
20. What is your date of birth?
mo day
yr
VA FORM
PAGE 1
SUPERSEDES VA FORM 21-534, JUN 1998,
21-534
MAR 2009
WHICH WILL NOT BE USED.
Note: Skip to Section IV if the veteran was receiving VA compensation or pension at the
SECTION III
time of his/her death.
21a. Entered Active
21b. Place
21c. Service Number
Service (first period)
Tell us about the
veteran's active duty
service
mo day
yr
21d. Left This Active
21e. Place
21f. Branch of Service
21g. Grade, Rank,
Service
or Rating
1. Enter complete information for
all periods of service. If more
mo day
yr
space is needed use Item 48
21h. Entered Active
21i. Place
21j. Service Number
"Remarks."
Service (second period)
2. If the veteran never filed a
mo day
yr
claim with VA, attach the
original DD214 or a certified
21k. Left This Active
21l. Place
21m. Branch of Service
21n. Grade, Rank,
copy for each period of service
Service
or Rating
listed. We will return original
documents to you.
mo day
yr
SECTION IV
You must furnish complete information about all marriages of the surviving
Tell us about
spouse and the veteran. If you need additional space, please attach a separate
your and the veteran's
sheet of paper providing the requested information.
marriages
If you are claiming benefits as the surviving spouse of the veteran you should
Attach a copy of your
complete Items 22a through 27. If you are not the surviving spouse, skip to
marriage certificate showing
Section V.
your marriage to the veteran.
The veteran's marriages
22a. How many times was the veteran married?
22b. Date of
22c. Place (city/state
22d. To whom married
22e. Type of marriage
22f. Date marriage
22g. Place (city/state
22h. How marriage
(ceremonial,
Marriage
or country)
(first, middle
ended
or country)
ended (death,
common-law, proxy,
(month, day, year)
initial, last name)
(month, day, year)
divorce)
tribal or other
22i. If you indicated "other" as type of marriage, please explain.
22j. At the time of your marriage to the veteran, were you aware of any reason the marriage might not be legally valid?
If you answered "Yes," please explain.
YES
NO
23a. How many times were you married?
23b. Have you remarried since the death of the veteran?
YES
NO
23d. Place (city/state
23h. Place (city/state
23c. Date of
23e. To whom married
23f. Type of marriage
23g. Date marriage
23i. How marriage
(ceremonial,
or country)
(first, middle
or country)
Marriage
ended
ended (death,
common-law, proxy,
(month, day, year)
initial, last name)
(month, day, year)
divorce)
tribal or other
23j. If you indicated "other" as type of marriage, please explain.
PAGE 2
VA FORM 21-534, MAR 2009
SECTION IV
Tell us about your and the veteran's marital history (continued)
24. Was a child born to you and the veteran
25. Are you expecting the birth of a child of
Answer Item 24 only if you
during your marriage or prior to your
the veteran?
were married to the veteran
marriage?
for less than one year.
YES
NO
YES
NO
26. Did you live continuously with the
27. What was the cause of the separation?
veteran from the date of marriage to the
Give the reason, date(s), and duration of the
date of his/her death?
separation. If the separation was by court
order, attach a copy of the order.
YES
NO
(If "No", answer Item 27)
SECTION V
Note: Skip to Section VI if you are not claiming benefits for any children that meet the
following criteria.
Tell us about the
VA recognizes the veteran's biological children, adopted children, and stepchildren as
unmarried children
dependents. These children must be unmarried and:
of the veteran
under age 18, or
at least 18 but under 23 and pursuing an approved course of education, or
Note: You should provide a copy
of any age if they became permanently unable to support themselves before
of the public record of birth or a
reaching age 18.
copy of the court record of
adoption for each child listed in
"Seriously disabled" (Item 29e) means that the child became permanently unable to support
Item 28a unless the veteran was
himself/herself before reaching age 18. Furnish a statement from an attending physician or
receiving additional VA benefits
other medical evidence which shows the nature and extent of the physical or mental impairment.
for the child.
If you need additional space,
Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over
please attach a separate sheet of
age 18 is entitled to receive DIC benefits in his or her own right. A veteran's child who is
paper providing the requested
seriously disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.
information about each child.
28a. Name of child
28b. Date and place
28c. Social Security
29a.
29b.
29c.
29d. 18 -
29e.
29f. Child
(First, middle initial,
of birth (City/State or
Number
Biological
Adopted
Stepchild
23 yrs old
Seriously
previously
Last)
Country)
and in
disabled
married
school
mo day
yr
mo day
yr
mo day
yr
PAGE 3
VA FORM 21-534, MAR 2009

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

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How to Fill out VA Form 21-534?

The fillable version of VA Form 21-534 was completed as follows:

  1. You entered your name and Social Security number (SSN), as well as the name & SSN the veteran, your contact information, and veteran VA file number in items 1 through 6E.
  2. You provided identification and service information in Part I. You needed to enter full data about each period of the veteran's active service. If the veteran had never claimed any benefits from the VA, you had to attach the corresponding discharge or separation documents.
  3. You had to indicate the specific details related to all marriages of the veteran and the surviving spouse in Part II.
  4. You had to provide the information concerning all children of the veteran Part III;
  5. You had to enter your net worth in Part IV.
  6. You had to provide the income of the surviving spouse, children, and custodian of the children in Part V. You were obliged to indicate all types of payments and incomes before any deductions or withholdings. You had to comment income reported in Items 27F and 28D in Item 37, "Remarks".
  7. You had to provide all deductible expenses, including veteran's last illness, burial, and debts in Part VI.
  8. Part VII contained miscellaneous questions and "Remarks" item.
  9. You entered the direct deposit data Part VIII.

You have to answer all the questions of the form. If the answer is "none", "0", or "unknown", you have to enter it in the corresponding field. After completion, you have to sign and date VA Form 21-534.

VA Form 21-534 Instructions

The instructions for the VA 21-534 were provided with the form. You had to read them carefully, detach, and keep for references. The general instructions were as follows:

  • You were required to submit the claim for Dependency and Indemnity Compensation within one year. Otherwise, the benefits were payable from the date the claim was received in the VA.
  • You had to file the pension claim within 45 days from the date of the veteran's death. If no, the payments were assigned since the date the form was received by the VA.
  • The pension rate depended on the family income amount and the number of dependent children. To receive the information about VA Form 21-534 income limits and benefit rates, you needed to call the local VA office at 1 800 827 1000.
  • An attorney, the accredited representative of a veteran organization, or representative of other service organization recognized by the Secretary of Veteran affairs could assist you with the claim.
  • If you were a minor or incompetent person, legal guardian or any other individual acting on your behalf could help filling out the VA Form 21-534.
  • If you were submitting VA aid and attendance form as a surviving spouse claiming the applicable benefits, you needed to provide a medical statement. If you were a nursing home patient, the statement signed by the nursing home official had to be attached.
  • Every applicant had the right to personal hearings at any stage of claim processing or after the decision was made. For this purpose, you needed to inform the nearest VA office about the wish, and the authorized representative arranged the time and place. You could bring witnesses and their testimonies were added to the records.
  • You had to provide the evidence requested in the form. If you could not attach the evidence, you had to enter the reason on a separate sheet and attach this sheet to the document.
  • If the evidence were already filed with the VA, you did not need to attach them again.

When submitting VA 21-534, you could also request Social Security (SS) benefits. The corresponding SSA-24 sheet was attached to the form.

Where to Mail VA Form 21-534?

You had to mail or take VA 21-534 to your regional VA Office. You could find its address in the blue pages of the telephone book under "United States Government, Veterans Affairs" or by calling the VA toll-free number, 1-800-827-1000. It was required to make a photocopy of the completed form for future references before submitting it to the VA office.

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