VA Form 21-534A Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child - in-Service Death Only

What Is VA Form 21-534A?

VA Form 21-534A, Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child - In-Service Death Only is a document needed to check the eligibility of surviving spouses and children of veterans who died during active duty service to receive benefits, dependency and indemnity compensation, death compensation, and/or death pension.

The latest version of the VA 21-534A Form was issued by the Department of Veterans Affairs (VA) in June 2014 with all previous editions obsolete. VA Form 21-543A fillable version is available for download below; however, it is no longer used. VA Form 21P-534A has replaced it, and you can download the new form to apply for Dependency and Indemnity below.

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OMB. Approved No. 2900-0004
Respondent Burden: 15 Minutes
Expiration Date: 1/31/2015
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION BY A SURVIVING
SPOUSE OR CHILD - IN-SERVICE DEATH ONLY
Privacy Act Notice: 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, and published
in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their
SSN under Title 38 USC 5101 (c) (1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law
in effect prior to January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of
determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by VA.
Respondent Burden: We need this information to determine eligibility for service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 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.
1. VETERAN'S FIRST - MIDDLE- LAST NAME
2. VETERAN'S SOCIAL SECURITY NO.
3. CLAIMANT'S FIRST - MIDDLE- LAST NAME
4. CLAIMANT'S SOCIAL SECURITY NO.
NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other service-connected
death benefits to which you and/or the deceased veteran's children may be entitled.
5. FOR SURVIVING SPOUSE ONLY:
I
have
have not lived continuously with the veteran from date of marriage to date of death.
If not, answer Item 6.
6. CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order,
7. DATE OF BIRTH OF SURVIVING
attach a copy of such order.)
SPOUSE (Mo., Day, Yr.)
8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
DATE OF BIRTH
SOCIAL SECURITY
PLACE OF BIRTH
FULL NAME
RELATIONSHIP TO CLAIMANT
(Mo., Day, Yr.)
NUMBER
(City and State)
9. CLAIMANT'S CURRENT MAILING ADDRESS
10. CLAIMANT'S TELEPHONE NUMBERS (Including Area Code)
11.
DAYTIME
EVENING
I
will
will not be changing my address.
12. CLAIMANT'S NEW ADDRESS
13. DATE OF ADDRESS CHANGE
want
do not want my VA payment to be directly deposited to my financial account.
14. I
15. ACCOUNT
CHECKING
ACCOUNT NUMBER
SAVING
FINANCIAL INSTITUTION'S NINE-DIGIT ROUTING OR TRANSIT NUMBER
I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
16. SIGNATURE OF CLAIMANT
17. DATE SIGNED
18. NAME AND RANK OF MILITARY
19. TELEPHONE NUMBER OF CAO
20. E-MAIL ADDRESS OF CAO
CASUALTY ASSISTANCE OFFICER (CAO)
PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a
material fact knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
21-534a
SUPERSEDES VA FORM 21-534A, OCT 2011,
Page 1
JUN 2014
WHICH WILL NOT BE USED.
OMB. Approved No. 2900-0004
Respondent Burden: 15 Minutes
Expiration Date: 1/31/2015
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION BY A SURVIVING
SPOUSE OR CHILD - IN-SERVICE DEATH ONLY
Privacy Act Notice: 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, and published
in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their
SSN under Title 38 USC 5101 (c) (1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law
in effect prior to January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of
determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by VA.
Respondent Burden: We need this information to determine eligibility for service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 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.
1. VETERAN'S FIRST - MIDDLE- LAST NAME
2. VETERAN'S SOCIAL SECURITY NO.
3. CLAIMANT'S FIRST - MIDDLE- LAST NAME
4. CLAIMANT'S SOCIAL SECURITY NO.
NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other service-connected
death benefits to which you and/or the deceased veteran's children may be entitled.
5. FOR SURVIVING SPOUSE ONLY:
I
have
have not lived continuously with the veteran from date of marriage to date of death.
If not, answer Item 6.
6. CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order,
7. DATE OF BIRTH OF SURVIVING
attach a copy of such order.)
SPOUSE (Mo., Day, Yr.)
8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
DATE OF BIRTH
SOCIAL SECURITY
PLACE OF BIRTH
FULL NAME
RELATIONSHIP TO CLAIMANT
(Mo., Day, Yr.)
NUMBER
(City and State)
9. CLAIMANT'S CURRENT MAILING ADDRESS
10. CLAIMANT'S TELEPHONE NUMBERS (Including Area Code)
11.
DAYTIME
EVENING
I
will
will not be changing my address.
12. CLAIMANT'S NEW ADDRESS
13. DATE OF ADDRESS CHANGE
want
do not want my VA payment to be directly deposited to my financial account.
14. I
15. ACCOUNT
CHECKING
ACCOUNT NUMBER
SAVING
FINANCIAL INSTITUTION'S NINE-DIGIT ROUTING OR TRANSIT NUMBER
I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
16. SIGNATURE OF CLAIMANT
17. DATE SIGNED
18. NAME AND RANK OF MILITARY
19. TELEPHONE NUMBER OF CAO
20. E-MAIL ADDRESS OF CAO
CASUALTY ASSISTANCE OFFICER (CAO)
PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a
material fact knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
21-534a
SUPERSEDES VA FORM 21-534A, OCT 2011,
Page 1
JUN 2014
WHICH WILL NOT BE USED.
INSTRUCTIONS FOR VA FORM 21-534a
PRINT ALL ANSWERS CLEARLY.
SIGN AND DATE THE APPLICATION.
MAKE A PHOTOCOPY OF THIS APPLICATION AND EVERYTHING YOU SUBMIT TO VA BEFORE YOU MAIL IT.
NOTE - All the information requested must be answered fully and clearly or action on your claim may be delayed. If you do not know
the answer, write "unknown."
SPECIFIC INSTRUCTIONS
ITEMS 1-2 - Self-explanatory.
ITEM 3 - Name of surviving spouse or person applying on behalf of minor children.
ITEMS 4-12 -Self-explanatory.
ITEM 13 - Expected date that new mailing address will be effective.
ITEMS 14-17 - Self-explanatory.
ITEMS 18-20 - To be completed by Military Casualty Assistance Officer.
MINORS AND INCOMPETENT PERSONS - If the person for whom the claim is being made is a minor or incompetent person,
the application 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.
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/.
THIS FORM, ALONG WITH THE SERVICE MEMBER'S DD FORM 1300, REPORT OF CASUALTY, SHOULD BE MAILED
OR FAXED TO:
DEPARTMENT OF VETERANS AFFAIRS
REGIONAL OFFICE AND INSURANCE CENTER
P.O. BOX 8079
PHILADELPHIA, PA 19101
FAX NUMBER (215) 381-3084.
For assistance in completing this application, or information about VA benefits and services, call us toll-free at
1-800-827-1000 (Hearing Impaired--TDD Line 1-800-829-4833).
Page 2
VA FORM 21-534a, JUN 2014

Download VA Form 21-534A Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child - in-Service Death Only

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VA Form 21-534A Instructions

  1. State the veteran's full name and social security number (SSN);
  2. Write down your full name, SSN, and date of birth. If you are a surviving spouse, state if you have lived with the veteran to the date of death;
  3. Specify the reason, the date, and the duration of separation if it is applicable;
  4. Write down the deceased veteran's children full names, dates, and places of birth, SSNs, and describe their relationship to you;
  5. Submit your current mailing address and telephone numbers. If the address changes in the future, write down the new address and the date of the change;
  6. State if you wish to receive the VA payment directly to your financial account;
  7. Provide information on your account - its type, number, and the transit number of the financial institution (bank);
  8. Confirm that the form contains only complete and true information to the best of your knowledge and belief;
  9. Sign the form and write down the date.

The last section of the form must be filled out by the Military Casualty Assistance Officer. The VA will assign the CAO to you in order to help you complete and submit the form. The CAO will write down the full name, the rank, the telephone number, and the e-mail address at the bottom of the document.

VA 21-534A Related Forms

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) is a related form submitted by a surviving spouse or child of a veteran to apply for various VA benefits and financial assistance the VA owes the deceased veteran. Unlike the previous form, this document is used when the death of the veteran occurred on active service, or as a result of a service-connected disability or a non-service connected injury during the time when the veteran was receiving VA compensation for a service-connected disability.

VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits is a related document completed by a surviving spouse or child to submit required evidence and information to justify and rationalize a claim for accrued benefits, dependency and indemnity compensation, or survivors pension.

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