VA Form 21-4182 Application for Dependency and Indemnity Compensation or Death Pension (Including Accrued Benefits and Death Compensation Where Applicable) From the Department of Veterans Affairs

VA Form 21-4182 is a United States Department of Veterans Affairs form also known as the "Application For Dependency And Indemnity Compensation Or Death Pension (including Accrued Benefits And Death Compensation Where Applicable) From The Department Of Veterans Affairs".

The latest fillable PDF version of the VA 21-4182 was issued on April 1, 2013 and can be downloaded down below or found on the Veterans Affairs Forms website.

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APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION OR DEATH PENSION
(INCLUDING ACCRUED BENEFITS AND DEATH COMPENSATION WHERE APPLICABLE) FROM THE
DEPARTMENT OF VETERANS AFFAIRS
(Supplement to Social Security Application Forms SSA-4, 5, 7 and 10)
(Type or print)
1B. VETERAN'S SOCIAL SECURITY NUMBER
(DO NOT WRITE IN THIS SPACE)
1A. FIRST - MIDDLE - LAST NAME OF DECEASED VETERAN
(Type or print)
(Check one)
2A. FIRST - MIDDLE - LAST NAME OF CLAIMANT
2B. RELATIONSHIP TO VETERAN
WIDOW
CHILD
PARENT
WIDOWER
3A. IF VETERAN PREVIOUSLY APPLIED TO VA FOR ANY BENEFITS,
INSERT VA FILE NUMBER, IF KNOWN
SURVIVING
DIVORCE SPOUSE
IDENTIFICATION AND SERVICE INFORMATION OF VETERAN
4. DATE OF BIRTH
5A. DATE OF DEATH
5B. PLACE OF DEATH
NOTE: The following information should be furnished for each period of the veteran's service in the Army, Navy, Air Force,
Marine Corps, or Coast Guard of the United States or service as a commissioned officer in the National Oceanic Atmospheric
Administration.
6D. GRADE, RANK OR RATING
6A. ENTERED ACTIVE SERVICE
6C. SEPARATED FROM ACTIVE SERVICE
6B. SERVICE
ORGANIZATION AND BRANCH OF
NUMBER
DATE
PLACE
DATE
PLACE
SERVICE
7. IF A VETERAN SERVED UNDER A NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME
(Sign in ink)
8B. DATE SIGNED
8A. SIGNATURE OF APPLICANT
(Include No. and street or rural route, City or P.O., State and ZIP Code)
9. ADDRESS
WITNESSES TO SIGNATURE OF CLAIMANT BY "X" MARK
NOTE: A signature by mark must be witnessed by two persons to whom the person making the statement is personally known. The witnesses must sign their names in
Items 10A and 11A and type or print their names and addresses in Items 10B and 11B.
10A. SIGNATURE OF WITNESS
11A. SIGNATURE OF WITNESS
(Type or print)
(Type or print)
10B. NAME AND ADDRESS OF WITNESS
11B. NAME AND ADDRESS OF WITNESS
ITEMS BELOW TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION OFFICE
REMARKS
ADDRESS OF TRANSMITTING SSA OFFICE
21-4182
VA FORM
SUPERSEDES VA FORM 21-4182, NOV 2001,
APR 2013
WHICH WILL NOT BE USED.
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION OR DEATH PENSION
(INCLUDING ACCRUED BENEFITS AND DEATH COMPENSATION WHERE APPLICABLE) FROM THE
DEPARTMENT OF VETERANS AFFAIRS
(Supplement to Social Security Application Forms SSA-4, 5, 7 and 10)
(Type or print)
1B. VETERAN'S SOCIAL SECURITY NUMBER
(DO NOT WRITE IN THIS SPACE)
1A. FIRST - MIDDLE - LAST NAME OF DECEASED VETERAN
(Type or print)
(Check one)
2A. FIRST - MIDDLE - LAST NAME OF CLAIMANT
2B. RELATIONSHIP TO VETERAN
WIDOW
CHILD
PARENT
WIDOWER
3A. IF VETERAN PREVIOUSLY APPLIED TO VA FOR ANY BENEFITS,
INSERT VA FILE NUMBER, IF KNOWN
SURVIVING
DIVORCE SPOUSE
IDENTIFICATION AND SERVICE INFORMATION OF VETERAN
4. DATE OF BIRTH
5A. DATE OF DEATH
5B. PLACE OF DEATH
NOTE: The following information should be furnished for each period of the veteran's service in the Army, Navy, Air Force,
Marine Corps, or Coast Guard of the United States or service as a commissioned officer in the National Oceanic Atmospheric
Administration.
6D. GRADE, RANK OR RATING
6A. ENTERED ACTIVE SERVICE
6C. SEPARATED FROM ACTIVE SERVICE
6B. SERVICE
ORGANIZATION AND BRANCH OF
NUMBER
DATE
PLACE
DATE
PLACE
SERVICE
7. IF A VETERAN SERVED UNDER A NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME
(Sign in ink)
8B. DATE SIGNED
8A. SIGNATURE OF APPLICANT
(Include No. and street or rural route, City or P.O., State and ZIP Code)
9. ADDRESS
WITNESSES TO SIGNATURE OF CLAIMANT BY "X" MARK
NOTE: A signature by mark must be witnessed by two persons to whom the person making the statement is personally known. The witnesses must sign their names in
Items 10A and 11A and type or print their names and addresses in Items 10B and 11B.
10A. SIGNATURE OF WITNESS
11A. SIGNATURE OF WITNESS
(Type or print)
(Type or print)
10B. NAME AND ADDRESS OF WITNESS
11B. NAME AND ADDRESS OF WITNESS
ITEMS BELOW TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION OFFICE
REMARKS
ADDRESS OF TRANSMITTING SSA OFFICE
21-4182
VA FORM
SUPERSEDES VA FORM 21-4182, NOV 2001,
APR 2013
WHICH WILL NOT BE USED.
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