If you have any questions about this form, how to fill it out, or

about VA benefits, contact your nearest VA regional office.

You can locate the address of the nearest regional office in

your telephone book blue pages under "United States

Government, Veterans" or call 1-800-827-1000 (Hearing Impaired

TDD line 1-800-829-4833). You may also contact VA by Internet

at https://iris.va.gov .

If it is determined that you are entitled to DIC and death

pension, we will pay you whichever benefit entitles you to the

most money. Benefit rates and income limits are frequently

changed, so it is not possible to keep this information current

in these instructions. You can find out what the current

income limitations and rates of benefits are by contacting your

nearest VA regional office.

GENERAL INSTRUCTIONS

Note: Read very carefully, detach, and keep these instructions for your reference.

A. How can I contact VA if I have questions?

B. What is the purpose of VA Form 21-534?

Use VA Form 21-534 to apply for:

C. What is the purpose of the attached SSA-24 form?

You can apply for Social Security (SS) benefits by using the

SSA-24 form attached to this VA Form (see pages 9

and 10). You don't have to apply if you don't want to or have

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

for you. They will then contact you.

D. What are dependency and indemnity compensation (DIC)

and death pension benefits, and how does VA decide what I

will or will not receive?

VA pays pension based on the amount of family income and

the number of dependent children. This is based on law. VA

must include as income all sources that Federal law specifies.

If there is no surviving spouse, pension may be payable on

behalf of a child or children.

F. How do I complete my application?

Print all answers clearly. If an answer is "none" or "0," write

that. Your answer to every question is important to help us

complete your claim. If you do not know the answer, write

"unknown." For additional space, use Item 48, "Remarks, " or

attach a separate sheet, indicating the item number to which

the answers apply. Make sure you sign and date this

application (Items 44 and 45).

1. Dependency and indemnity compensation may be payable

when:

a veteran's death occurred in service, or

a veteran dies of a service-connected disability, or

in certain circumstances if a veteran rated totally

disabled from service-connected disability dies from

non-service-connected conditions.

VA FORM

JUN 2005 21-534

E. How do I apply for aid and attendance allowance and/or

housebound benefits?

VA may pay a higher rate of DIC or pension to a surviving

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

wish to apply for this benefit, check "Yes" for Item 31.

SUPERSEDES VA FORM 21-534, JUN 1998,

WHICH WILL NOT BE USED.

VA benefits you may be entitled to receive as a

surviving spouse or child of a deceased veteran, and

any money VA owes the veteran but did not pay

prior to his/her death (accrued benefits).

If you apply for any one of these benefits, the law requires that

we also consider you for the others.

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.

Unless a claim for dependency and indemnity compensation

or death pension is filed within one year from the date of the

veteran's death, that benefit is not payable from a date earlier

than the date the claim is received in the VA.

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

2. Death pension may be payable when:

the death of a veteran with wartime service is

not due to service, and

income is within applicable limits.

PAGE 1 General

Instructions
H. How can I assign someone to act as my representative?

I. What if I believe that VA has made an error in processing

or deciding my benefits?

G. What do I do when I have completed my application?

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 o f 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 Compensation, Pension, Education, and Rehabilitation 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). The VA wil 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 75 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/library/omb/OMBINVC.html#VA. If

desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

General

Instructions

A representative can be an accredited member of an accredited

organization orother service organization that the Secrertary of

Veterans Affairs recognizes, an agent recognized by VA, or a

licensed lawyer. Agents and attorneys can charge you for

services that you get from them only after the Board of

Veteran's Appeals (BVA) gives you their final decision about

your application. That means you can use an attorney during

any stage of your application for benefits. However, the agent

or attorney cannot charge your for services unless you are

trying to resolve a dispute with VA after BVA has made a

decision about your claim.

When you have completed this application mail it or take it to

a VA regional office. Be sure to attach any materials that

support and explain your claim. Also, make a photocopy of

your application and everything that you submit to VA before

mailing it.

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

download these forms at http://www.va.gov/vaforms/. If you

have already designated a representative, no further action is

required on your part.

You can ask for a personal hearing at any time during the

processing of your claim. That means you can ask for the

hearing while VA is processing your claim or after VA has

made a decision. You should contact the nearest VA office

and tell them that you want a personal hearing on your case.

Someone in the local VA office will arrange a time and place

for your hearing. At this hearing, you can bring witness. VA

will record whatever you and your witness say during the

hearing and include it in the official record. VA will furnish

the hearing room and officials, and prepare a transcript of the

hearing. VA cannot pay your expenses or the expenses of

anyone you want to bring with you to the hearing.

PAGE 2 VA FORM 21-534, JUN 2005
Please read the attached "General Instructions" before you fill out this form.

SECTION

I

5. What is the name of the person on whose service the claim was filed?

2. What is the VA file number?

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

OMB Approved No. 2900-0004

Respondent Burden: 1 hour 15 minutes

VA FORM

JUN 2005 21-534 SUPERSEDES VA FORM 21-534, JUN 1998, PAGE 1

WHICH WILL NOT BE USED.

Tell us

about you

and the

deceased

veteran

SECTION

II

Tell us what you

are applying for

and what you and

the deceased

veteran have

applied for

1. Did the veteran ever file a claim with VA?

3. Has the surviving spouse or child ever filed a

claim with VA?

4. What is the VA file number?

6. What is your relationship to that person?

7. Are you claiming service connection for cause of death?

8. What is the veteran's name?

9. What is the veteran's Social Security number? 10a. Did the veteran serve under another name?

(If "Yes," answer Items 10b)

10b.

First Middle Last Suffix (If applicable)

Please list the other name(s) the veteran

served under:

mo day yr

11. What is the veteran's date of birth?

12. What is the veteran's date of death? 13. Was the veteran a former prisoner of war?

14. What is your name? (First, Middle, Last Name) 15. What is your relationship to the veteran?

 (check one)

16. What is your address?

City

Street address, Rural Route, or P.O. Box

17. What are your telephone numbers?

 (Include Area Code)

18. What is your e-mail address?

Apt. number

State ZIP Code Country

Attach a copy of the

death certificate

unless the veteran

died in active service

of the Army, Navy,

Air Force, Marine Corps,

or Coast Guard, or in a

U.S. government

institution.

19. What is your Social Security number? 20. What is your date of birth?

(If "Yes," answer Item 2)

(If "Yes," answer Items 4

through 6)

First Middle Last

mo day yr

mo day yr

 YES NO

 YES NO

 YES NO

 YES NO

 YES NO

 Surviving Spouse Child

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
Tell us

about the

veteran's

active duty

service

 PAGE 2

SECTION

III

1. Enter complete information for

all periods of service. If more

space is needed use Item 48

"Remarks."

2. If the veteran never filed a

claim with VA, attach the

original DD214 or a certified

copy for each period of service

listed. We will return original

documents to you.

21a. Entered Active

Service (first period)

mo day yr

The surviving spouse's marriages. Note: Items 23a through 27 should be completed by the veteran's surviving spouse.

If the claimant is not the surviving spouse, skip to Section V.

Tell us about

your and the

veteran's

marital history

The veteran's marriages

22b. Date of

 Marriage

mo day yr

mo day yr

22c. Place 22d. To whom

 married

22e. Date marriage

 ended

mo day yr

mo day yr

22f. Place 22g. How marriage

 ended

(city/state or country) (death, divorce)

23a. How many times were you married?

23c. Date of

 Marriage

mo day yr

mo day yr

23d. Place 23e. To whom

 married

23f. Date marriage

 ended

mo day yr

mo day yr

23g. Place 23h. How marriage

 ended

SECTION

IV

22a. How many times was the veteran married?

(first, middle initial,

last name) (city/state or country)

(city/state or country) (city/state or country) (death, divorce)

21g. Grade, Rank,

 or Rating

21f. Branch of Service

Note: Skip to Section IV if the veteran was receiving VA compensation or pension at the

time of his/her death.

Attach a copy of your marriage

certificate showing your marriage

to the veteran.

23b. Have you remarried since the death of the veteran?

(first, middle initial,

last name)

You must furnish complete information about all marriages of the surviving

spouse and the veteran. If you need additional space, please attach a separate

sheet of paper providing the requested information about the marriages.

mo day yr

21b. Place 21c. Service Number

21d. Left This Active

Service

21e. Place

21h. Entered Active

Service (second period)

mo day yr

21n. Grade, Rank,

 or Rating

21m. Branch of Service

mo day yr

21i. Place 21j. Service Number

21k. Left This Active

Service

21l. Place

Note: Skip to Section V if the veteran was receiving additional VA benefits for you

as his/her spouse at the time of his/her death unless you remarried after the

veteran's death.

 YES NO

VA FORM 21-534, JUN 2005
 PAGE 3

Tell us

about the

unmarried

children of

the veteran

VA recognizes the veteran's biological children, adopted children, and stepchildren as

dependents. These children must be unmarried and:

SECTION

V

under age 18, or

between 18 and 23 and pursuing an approved course of education, or

of any age if they became permanently unable to support themselves before

reaching age 18.

If you need additional space,

please attach a separate sheet of

paper providing the requested

information about each child.

24. Was a child born to you and the veteran

during your marriage or prior to your

marriage?

25. Are you expecting the birth of a child of

the veteran?

26. Did you live continuously with the

veteran from the date of marriage to the

date of his/her death?

(If "No", answer Item 27)

Answer Item 24 only if you

were married to the veteran

for less than one year.

Note: Skip to Section VI if you are not claiming benefits for any children that meet the

following criteria.

SECTION IV Tell us about your and the veteran's marital history (continued)

"Seriously disabled" (Item 29e) means that the child became permanently unable to support

himself/herself before reaching age 18. Furnish a statement from an attending physician or

other medical evidence which shows the nature and extent of the physical or mental impairment.

Note: You should provide a copy

of the public record of birth or a

copy of the court record of

adoption for each child listed in

Item 28a unless the veteran was

receiving additional VA benefits

for the child.

28a. Name of child

(First, middle initial,

Last)

28b. Date and place

of birth (City/State or

Country)

28c. Social Security

Number

29f. Child

previously

married

29e.

Seriously

disabled

29d. 18 -

23 yrs old

and in

school

29c.

Stepchild

29b.

Adopted

29a.

Biological

mo day yr

mo day yr

mo day yr

27. What was the cause of the separation?

 Give the reason, date(s), and duration of the

separation. If the separation was by court

order, attach a copy of the order.

Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over

age 18 is entitled to receive DIC benefits in his or her own right. A veteran's child who is

seriously disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.

 YES NO YES NO

 YES NO

VA FORM 21-534, JUN 2005
Tell us if

you are

housebound,

in a nursing

home or

require aid

and

attendance

 PAGE 4

Tell us about the children listed above that don't live with you.

30a. Name of child

 (first, middle initial, last)

30b. Child's Complete Address 30c. Name of person the child

 lives with (if applicable)

30d. Monthly amount you

 contribute to child's

 support

SECTION

VI

32a.

32d.

31. Are you claiming aid and attendance

allowance and/or housebound benefits

because you need the regular assistance of

another person, are having severe visual

problems, or are housebound?

Are you now in a nursing home?

Have you applied for Medicaid?

If you answered "yes" to Item 31

and are not in a nursing home,

submit a statement from your

doctor showing the extent of

your disabilities. If you are in a

nursing home, attach a statement

signed by an official of the

nursing home showing the date

you were admitted to the nursing

home, the level of care you

receive, the amount you pay outof-pocket for your care, and

whether Medicaid covers all or

part of your nursing home costs.

(If "Yes," answer Items 32b and 32c also)

32b. What is the name and complete mailing

address of the facility?

(If "No," answer Item 32d also)

32c. Does Medicaid cover all or part of your

nursing home costs?

SECTION V Tell us about the unmarried children of the veteran (continued)

$

$

$

(If "No," skip to section VII)

$

 YES NO YES NO

 YES NO

 YES NO

VA FORM 21-534, JUN 2005
SECTION

VII

Tell us the net

worth of you and

your dependents

 PAGE 5

VA cannot pay you pension if your net worth is sizeable. Net worth is the market value of

all interest and rights you have in any kind of property less any mortgages or other claims

against the property. However, net worth does not include the house you live in or a

reasonable area of land it sits on. Net worth also does not include the value of personal

things you use everyday like your vehicle, clothing, and furniture. You must report net

worth for yourself and all persons for whom you are claiming benefits.

For Items 33a through 33f, provide the amounts. If none, write "0" or "None."

Source

33a. Cash, bank accounts, certificates

of deposit (CDs)

33b. IRAs, Keogh Plans, etc.

33c. Stocks, bonds, mutual funds

Surviving spouse or

Custodian of children

Child(ren)

33f. All other property

33e. Real property (not your home)

Name: Name: Name:

33d. Value of business assets

(first, middle initial, last) (first, middle initial, last) (first, middle initial, last)

Payments from any source will be

counted, unless the law says that they

don't need to be counted. Report all

income, and VA will determine any

amount that does not count.

SECTION

VIII

Report the total amounts before you take out deductions for taxes, insurance, etc.

Do not report the same information in both tables.

If you expect to receive a payment, but you don't know how much it will be, write

"Unknown" in the space.

If you do not receive any payments from one of the sources that we list, write "0" or

"None" in the space.

If you are receiving monthly benefits, give us a copy of your most recent award letter.

This will help us determine the amount of benefits you should be paid.

34a.

Tell us about the

income of you and

your dependents

Note: If you are filing this application

on behalf of a minor or incompetent

child of the veteran and you are the

child's custodian, you must report your

net worth as well as the net worth of the

child for whom benefits are claimed.

Note: If you are filing this application

on behalf of a minor of whom you are

the custodian, you must report your

income as well as the income of each

child for whom benefits are claimed.

Have you claimed or are you receiving

benefits from the Social Security

Administration on your own behalf or on

behalf of child(ren) in your custody?

(If "Yes," answer item 34b)

34b. Is Social Security based on your own

employment?

35. Has a surviving spouse or child filed a

claim for compensation from the Office of

Worker's Compensation Programs based

on the death of the veteran?

36. Has a court awarded damages based on

the death of the veteran or is a claim or

legal action for damages pending?

37. Have you claimed or are you receiving Survivor Benefit Plan (SBP) annuity from a

service department based on the death of the veteran?

 YES NO

 YES NO

 YES NO

 YES NO

 YES NO

VA FORM 21-534, JUN 2005
Monthly Income - Tell us the income you and your dependents receive every month

Source

Name:

Child(ren)

Name: Name:

38g. Other income received monthly

(Please write source below:)

38f. Supplemental Security Income

(SSI)/ Public Assistance

38e. Black Lung Benefits

38c. U.S. Railroad Retirement

38b. U.S. Civil Service

38a. Social Security

Sources of income

for the next 12

months

Expected income next 12 months - Tell us about other income for you and your dependents

Name: Name: Name:

Child(ren)

39a. Gross wages and salary

39b. Total dividends and interest

39d. Other income expected

(Please write source below:)

38d. Military Retirement

PAGE 6

(first, middle initial, last) (first, middle initial, last) (first, middle initial, last)

(first, middle initial, last) (first, middle initial, last) (first, middle initial, last)

Surviving spouse or

Custodian of children

Report expected income for the 12 month period following the veteran's death. If the claim is filed more than one year after the veteran

died, report the expected income for the 12 month period from the date you sign this application.

Surviving spouse or

Custodian of children

SECTION VIII Tell us about the income of you and your dependents (continued)

39c. Other income expected

(Please write source below:)

VA FORM 21-534, JUN 2005
40a. Amount paid by

 you

40e. Relationship of person for

 whom expenses paid

SECTION IX

Tell us about medical,

last illness, burial or

other unreimbursed

expenses

40b. Date Paid 40c. Purpose (Medicare

 deduction, nursing

 home costs, burial

 expenses, etc.)

40d. Paid to (Name of

 nursing home,

 hospital, funeral

 home, etc.)

Family medical expenses and certain other expenses actually paid by you may be deductible from your

income. Show the amount of any continuing family medical expenses such as the monthly Medicare

deduction or nursing home costs you pay. Also, show unreimbursed last illness and burial expenses and

educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are

unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the

veteran's just debts. Educational or vocational rehabilitation expenses are amounts paid for courses of

education, including tuition, fees, and materials. Do not include any expenses for which you were

reimbursed. If you receive reimbursement after you have filed this claim, promptly advise the VA

office handling your claim. If more space is needed attach a separate sheet.

All Federal payments beginning January 2, 1999, must be made by electronic funds transfer (EFT) also

called Direct Deposit. Please attach a voided personal check or deposit slip or provide the information

requested below in Items 41, 42, and 43 to enroll in Direct Deposit. If you do not have a bank account

we will give you a waiver from Direct Deposit, just check the box below in Item 41. The Treasury

Department is working on making bank accounts available to you. Once these accounts are available,

you will be able to decide whether you wish to sign-up for one of the accounts or continue to receive a

paper check. You can also request a waiver if you have other circumstances that you feel would cause

you a hardship to be enrolled in Direct Deposit. You can write to: Department of Veterans Affairs, 125

S. Main Street Suite B, Muskogee OK 74401-7004, and give us a brief description of why you do not

wish to participate in Direct Deposit.

If benefits are awarded we

will need more information

in order to process any

payments to you. Please read

the paragraph starting with,

"All Federal payments..."

and then either:

42. Name of financial institution

43. Routing or transit number

Account number

41. Account number (Please check the appropriate box and provide that account number, if applicable)

 PAGE 7

1. Attach a voided

 check, or

2. Answer questions 41-43

 to the right.

I certify that I do not have an account with a financial

institution or certified payment agent Savings

Checking

SECTION

X

mo day yr

mo day yr

mo day yr

mo day yr

Give us direct deposit

information

$

$

$

$

VA FORM 21-534, JUN 2005
Remarks - Use this

space for any additional

statements that you

would like to make

concerning your

application.

I certify and authorize the release of information:

I certify that the statements in this document are true and complete to the best of my knowledge. I

authorize any person or entity, including but not limited to any organization, service provider,

employer, or government agency, to give the Department of Veterans Affairs any information about

me except protected health information, and I waive any privilege which makes the information

confidential.

44. Your signature

46b. Printed name and address of witness

45. Today's date

46a. Signature of witness (If claimant

signed above using an "X")

47a. Signature of witness (If claimant

 signed above using an "X")

47b. Printed name and address of witness

IMPORTANT

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 which you are

not entitled to.

48.

Give us your

signature

PAGE 8

SECTION

XII

SECTION

XI

Remarks (If you need more space to answer a question or have a comment about a specific item number

on this form please identify your answer or statement by the part and item number)

1. Read the box that starts,

"I certify and authorize the

release of information:"

2. Sign the box that says,

"Your signature."

3. If you sign with an "X,"

then you must have 2

people you know witness

you as you sign. They must

then sign the form and

print their names and

addresses also.

VA FORM 21-534, JUN 2005
 4. DATE OF BIRTH

Form Approved

OMB Approved No. 0960-0062

(DO NOT WRITE IN THIS SPACE)

VA DATE STAMP

 1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.

 3. SOCIAL SECURITY NO. OF VETERAN

 2. DATE OF DEATH

 5. PLACE OF BIRTH

 6. NAME OF FATHER 7. MAIDEN NAME OF MOTHER 8. DID THE VETERAN WORK IN THE RAILROAD

 INDUSTRY AT ANY TIME AFTER 1936?

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the

military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric

Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.

9A. DATE ENTERED ACTIVE SERVICE 9B. SERVICE NO. 9C. DATE SEPARATED FROM ACTIVE

SERVICE

9D. GRADE, RANK, OR RATING, ORGANIZATION

AND BRANCH OF SERVICE

 10. RELATIONSHIP OF APPLICANT TO VETERAN 11. DATE OF BIRTH OF APPLICANT 12. VA FILE NO.

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including

stepgrandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c)

disabled or handicapped (18 or over and disability began before age 22).

 13A.

 13C.

 13B.

 13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a

right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I

have given in this document is true.

 14. DATE (Month, day, year) 15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)

 16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code) 17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE

 19A. SIGNATURE OF WITNESS 19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

 18A. SIGNATURE OF WITNESS

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"

 18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

 22. DATE 23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

 20. PROOFS RECEIVED 21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)

OTHER (Specify)

MARRIAGE

AGE

DEATH

(NAME)

(NAME)

(NAME)

(NAME)

OTHER (Specify)

MARRIAGE

AGE

DEATH

(NAME)

(NAME)

PAGE 9

SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SURVIVORS BENEFITS

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)

IMPORTANT - Read instructions before completing form. Detach and retain ONLY the instruction sheet.

Form SSA-24 (2-2002) Destroy All Prior Editions

 YES NO

 SURVIVING SPOUSE CHILD PARENT
PAGE 10

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.

INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS

(Payable Under Title II of the Social Security Act)

enable a third party or an agency to assist Social Security in establishing an individual's

right to benefits or coverage;

comply with Federal laws which require or authorize the release of information from social

security records; and

facilitate statistical research and audit activities necessary to assure the integrity and

improvement of the social security programs.

If you should have any question about entitlement to social security benefits or the information you have

provided on this form, please contact your local social security office.

Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When

signed and dated the form SHOULD BE LEFT ATTACHED to your completed

VA Form21-534, Application for Dependency and Indemnity Compensation, Death Pension a

nd Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if

Applicable) or

VA Form 21-535, Application for Dependency and Indemnity Compensation by Parent(s)

(Including Accrued Benefits and Death Compensation When Applicable).

This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the

Social Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the

application requests information in order to determine eligibility to social security benefits.

You do not have to complete this application; there are no penalties under the law if you do not complete

part or all of the SSA-24. However, it is usually to your advantage to provide the information because not

providing it could prevent an accurate and timely decision on your claim or could result in the loss of

some benefits or insurance coverage.

If you do wish to supply the information requested on the SSA-24, this information will be forwarded to

the Social Security Administration and used by them to determine wheter social security benefits may be

payable to surviving dependent(s) of the veteran. Social Security will then contact you regarding any

social security benefits payable based on information given on this form.

Please understand that Social Security may, in certain instances, disclose the information on this form to

another Federal, State or local agency or individual without your written consent. This would be done in

order to:

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of

44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required

to answer these questions unless we display a valid Office of Management and Budget control number.

We estimate that it will take you about 15 minutes to read the instructions, gather the necessary facts, and

answer the questions.