Fillable INSTRUCTIONS FOR VA FORM 21P-601 APPLICATION FOR ACCRUED (U.S. Department of Veterans Affairs)

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INSTRUCTIONS FOR VA FORM 21P-601 APPLICATION FOR ACCRUED (U.S. Department of Veterans Affairs)

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INSTRUCTIONS FOR VA FORM 21P-601
APPLICATION FOR ACCRUED AMOUNTS DUE A DECEASED BENEFICIARY
Note: Do not complete this form if you have applied for death benefits by using VA Form 21P-534 or 21P-535. Read very
carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
B. What do I use VA Form 21P-601 for?
C. What are accrued benefits and how does VA decide what I will or will not receive?
When the deceased beneficiary is a
veteran, accrued is payable
When the deceased beneficiary is a
surviving spouse, accrued is payable
When the deceased beneficiary is a
child, accrued is payable
in full to the surviving spouse, or
in equal shares to the veteran's children (see
definition of "child" below), or
in equal shares to the veteran's parents, if
they are dependent upon the veteran at the
date of the veteran's death, or
in full to the sole surviving parent, if he/she
is dependent upon the veteran at the date of
the veteran's death.
in equal shares to the veteran's
children who are entitled to death
compensation, dependency and
indemnity compensation, or death
pension (see definition of "child"
below).
in equal shares to the veteran's
children (see definition of
"child" below).
VA FORM
SEP 2019
SUPERSEDES VA FORM 21P-601, SEP 2016,
WHICH WILL NOT BE USED.
21P-601
If you have questions about this form, how to fill it out, or about benefits, contact your nearest VA regional office. You can locate the
address of the nearest regional office online at https://www.va.gov/find-locations/, in your telephone book blue pages under "United
States Government, Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 711.) You may also contact VA by Internet at
https://iris.custhelp.com.
Note: If you are a deceased veteran's surviving spouse, child, or dependent parent, you may apply for death benefits, including
accrued benefits, using VA Form 21P-534EZ, Application for DIC, Death Pension and/or Accrued Benefits.
Use VA Form 21P-601 to apply for accrued benefits due the beneficiary but not paid prior to death. Each person claiming a share of
accrued benefits must complete a separate VA Form 21P-601.
Any available accrued benefits are payable to the first living person listed below. The fact that a preferred beneficiary fails to file or
prosecute a claim does not permit payment of his/her share of accrued benefits to a person or persons having an equal or lower
preference. A waiver of right also does not permit such payment. If there are no living persons who are entitled on the basis of
relationship, accrued benefits may be payable as reimbursement for last illness and burial expenses (see Paragraph D.)
Accrued benefits are benefits that were due the beneficiary at the time of death but not paid prior to death. Entitlement to accrued
benefits is determined according to the line of succession established by law.
A person eligible for accrued benefits may request to substitute for a deceased claimant who had a pending claim or appeal at the time
of his or her death. Substitution allows a person to submit evidence in support of the pending claim or appeal for potential accrued
benefits.
The right to substitute may be waived by marking "yes" in the designated box on this form. If the right to substitute is waived, VA
may still consider the accrued claim; however, VA will do so based only on the evidence contained in the claims folder at the time of
death.
Definitions:
Child means an unmarried child of the veteran who is under 18 years of age, or at least 18 but under 23 years of age and pursuing an
approved course of education, or became incapable of self-support prior to reaching age 18. However, benefits may be payable to the
veteran's children, regardless of age or marital status, if lump sum accrued benefits are payable.
Lump sum accrued benefits are amounts withheld from a competent veteran's Old Law Pension benefits (fixed rate since 1960)
during hospital treatment, or institutional or domiciliary care.
Page 1
E. What are the time limits to apply for accrued benefits?
F. What evidence should I submit?
the dates, nature, and costs of services or supplies provided,
the name of the deceased for whom the expenses were incurred, and
whether the expense has been paid, and, if so, by whom.
G. How do I complete my application?
H. What do I do when I have completed my application?
Exception: A claim for lump sum accrued benefits (benefits that were withheld from a competent veteran during hospital treatment,
institutional, or domiciliary care) must be filed within five years from the veteran's date of death. However, if the person who is
entitled to the lump sum accrued benefits has been declared incompetent by a court of law or Federal or State government agency at
the time of the veteran's death, the five-year period begins from the date of termination or removal of the finding of incompetency.
A claim for accrued benefits must be filed within one year from the date of death of the deceased beneficiary.
1. Furnish a copy of the death certificate unless the beneficiary died in a VA medical facility.
2. If an executor or administrator of the beneficiary's estate has been assigned, submit a certified copy of the letters of administration
or letters testamentary bearing the signature and seal of the appointing court.
3. If you are claiming reimbursement for last illness and burial expenses of a beneficiary, submit all bills and statements of account
covering the services and supplies that were provided in connection with these expenses. The bill or statement of account should be
submitted on the regular billhead of the creditor and show:
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 26, "Remarks, " or attach a separate
sheet, indicating the item number to which the answers apply. Write the veteran's name and VA file number on all attachments. Make
sure you sign and date this application (Items 23a and 23b.)
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 you mail it.
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 5, 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. You are required to respond to obtain or retain benefits per 38 U.S.C § 501. 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 submitted is subject to verification through computer matching programs with other agencies. You are
required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as
authorized under the Privacy Act, and, specifically may disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine eligibility for payment of accrued benefits under 38 U.S.C. 5121.
Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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 http: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.
D. Who may file a claim for reimbursement for last illness and burial expenses?
If there are no living persons who are entitled on the basis of relationship, accrued benefits may be used to reimburse the person or
persons who paid for or are responsible to pay the expenses of last illness and burial of a beneficiary. The claim should be filed by the
person or persons whose funds were or will be used to pay such expenses. If the expenses were paid from funds of the deceased
beneficiary's estate, the claim should be filed by the executor or administrator of the estate. If the expenses have not been paid, the
claim may be filed by the person who is responsible for the payment of these expenses. However, all unpaid creditors must sign
Section IV, Waiver of Reimbursement From All Unpaid Creditors.
VA FORM 21P-601, SEP 2019
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/.
Page 2
OMB Approved No. 2900-0216
Respondent Burden: 30 Minutes
Expiration Date: 9-30-2022
APPLICATION FOR ACCRUED AMOUNTS DUE A DECEASED BENEFICIARY
1. VETERAN'S NAME (First, Middle Initial, Last)
2. VETERAN'S SOCIAL SECURITY NUMBER
5. BENEFICIARY DATE OF DEATH (MM,DD,YYYY)
3. VETERAN'S FILE NUMBER
YearDayMonth
NOTE: Please read the attached "Instructions" before you fill out this form.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
4. NAME OF DEACEASED BENEFICIARY (If other than veteran - First, Middle Initial, Last)
6. CLAIMANT'S NAME (First, Middle Initial, Last)
7. CLAIMANT'S SOCIAL SECURITY NUMBER
8. CLAIMANT'S DATE OF BIRTH (MM,DD,YYYY)
YearDayMonth
9. CLAIMAINT'S CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
SECTION I: CLAIMANT AND DECEASED BENEFICIARY INFORMATION
10. CLAIMANT'S TELEPHONE NUMBER (Include Area Code) 11. PREFERRED E-MAIL ADDRESS (If applicable)
12. CLAIMANT'S RELATIONSHIP
TO DECEASED BENEFICIARY
SECTION II: DECEASED BENEFICIARY'S SURVIVING RELATIVES
SPOUSE
CHILD OR CHILDREN (See instructions for definition of a child.)
PARENT
NONE (If "NONE," Skip to Question 14)
14. RELATIVES SURVIVING BENEFICIARY AT TIME OF DEATH
VA FORM
SEP 2019
21P-601
SUPERSEDES VA FORM 21P-601, SEP 2016,
WHICH WILL NOT BE USED.
Page 3
13A. NAME
(First, Middle Initial, Last)
13B. RELATIONSHIP TO
BENEFICIARY
13C. DATE OF BIRTH
(MM/DD/YYYY)
13D. COMPLETE MAILING ADDRESS
14. WOULD YOU LIKE TO WAIVE SUBSTITUTION?
YES NO
(If "YES," see Paragraph C of the Instructions)
13. WHO ARE THE DECEASED BENEFICIARY'S SURVIVING RELATIVES? (Check all that apply. List each person separately in Items 13A through 13D)
SECTION III: INFORMATION ABOUT DEBTS, EXPENSES AND BURIAL OF DECEASED BENEFICIARY
NOTE: Read Paragraphs C and D of the Instructions before completing Section III. Complete this section only if you are claiming accrued benefits for reimbursement of expenses for last
illness or burial. Skip to Section V if you are claiming accrued benefits based on your relationship to the deceased beneficiary.
15. LIST THE EXPENSES OF LAST SICKNESS AND BURIAL IN ITEMS 15A THROUGH 15E.
15A. NAME OF PERSON OR FIRM
15B. NATURE OF EXPENSE
(For example, physician,
hospital, burial expenses,
etc.)
15C. AMOUNT 15D. CHECK ONE
15E. IF PAID, NAME OF PERSON OR
ESTATE WHOSE FUNDS WERE USED
UNPAID
PAID
$
$
$
$
16. HAVE YOU BEEN RIMBURSED FROM ANY SOURCE FOR ANY OF THE EXPENSES PAID FROM YOUR PERSONAL FUNDS?
YES NO
17. DID THE BENEFICIARY LEAVE ANY OTHER DEBTS?
YES NO
(If "YES," specify the amount and source)
(If "YES," go to Item 18)
(If "NO," skip to Item 19)
18. LIST THE OTHER DEBTS IN ITEMS 18A AND 18B.
$
$
$
$
18B. AMOUNT
18A. NATURE OF DEBT
19. HAS OR WILL THE BENEFICIARY'S ESTATE BE LEGALLY ADMINISTERED?
YES NO
(If "YES," attach a copy of the letters of administration or letters
testamentary bearing the signature and seal of the appointing court)
SECTION IV: WAIVER OF REIMBURSEMENT FROM ALL UNPAID CREDITORS
NOTE: If any of the expenses listed in Item 15D are unpaid, Section IV must be completed and signed by all unpaid creditors. If you are a creditor who is claiming accrued benefits as
reimbursement, Section IV must be completed by all other creditors and persons who provided services to the deceased beneficiary related to last illness or burial and hold the creditor responsible
for payment of their claims. If you need additional space, please attach a separate sheet of paper providing the certification and information requested below.
I CERTIFY THAT the expense listed in Section III, Item 15D which was incurred by the claimant named in Item 6 in connection with the last sickness and burial of the beneficiary, is due and
unpaid. I further certify that I hold the claimant responsible for the payment of any portion of the accrued benefit to which I may be entitled in the case of the beneficiary named in Item 1 or 4
and waive my right to any such benefit. This statement is true and correct to the best of my belief.
20A. NAME OF UNPAID CREDITOR OR FIRM NO. 1
20B. ADDRESS OF CREDITOR OR FIRM
20C. SIGNATURE OF CREDITOR OR PERSON SIGNING FOR FIRM (Sign in ink)
20D. TITLE
20E. DATE SIGNED (MM/DD/YYYY)
VA FORM 21P-601, SEP 2019
Page 4
$
SECTION IV: WAIVER OF REIMBURSEMENT FROM ALL UNPAID CREDITORS (Continued)
21A. NAME OF UNPAID CREDITOR OR FIRM NO. 2
21B. ADDRESS OF CREDITOR OR FIRM
21C. SIGNATURE OF CREDITOR OR PERSON SIGNING FOR FIRM (Sign in ink)
21D. TITLE
21E. DATE SIGNED (MM/DD/YYYY)
22A. NAME OF UNPAID CREDITOR OR FIRM NO. 3
22B. ADDRESS OF CREDITOR OR FIRM
22C. SIGNATURE OF CREDITOR OR PERSON SIGNING FOR FIRM (Sign in ink)
22D. TITLE
22E. DATE SIGNED (MM/DD/YYYY)
SECTION V: SIGNATURE
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief. (If you sign with an "X," then you must have two people witness you as you sign.
They must sign the form and print their names and addresses.)
23A. SIGNATURE OF CLAIMANT (Sign in ink)
23B. TODAY'S DATE (MM/DD/YYYY)
24A. SIGNATURE OF WITNESS (If claimant signed above using an "X" - Sign in ink)
25A. SIGNATURE OF WITNESS (If claimant signed above using an "X" - Sign in ink)
24B. PRINTED NAME AND ADDRESS OF WITNESS
25B. PRINTED NAME AND ADDRESS OF WITNESS
SECTION VI: REMARKS
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. (18 U.S.C. §§ 1001-1002)
26. REMARKS
Page 5
VA FORM 21P-601, SEP 2019
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INSTRUCTIONS FOR VA FORM 21P-601 APPLICATION FOR ACCRUED (U.S. Department of Veterans Affairs)

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