Fillable NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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BROWSE COUNTY OF FULTON (NY) FORMS

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FDC Criteria (Claim(s) for DIC, Death Pension, and/or Accrued Benefits)
1. Submit your claim on a signed and completed VA Form 21-534EZ, Application for DIC, Death Pension, and/or
Accrued Benefits (Attached).
2. Submit simultaneously with your claim:
A copy of the veteran's Death Certificate (unless he or she died on active duty); AND
.
If claiming DIC:
Requirements for Certain Claimants:
If claiming death pension:
All necessary income and net-worth information
If claiming death pension with increased survivor benefits, a completed VA Form 21-2680, Examination for
Housebound Status or Permanent Need for Regular Aid and Attendance, and a completed VA Form 21-0779,
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
All, if any, relevant, private medical treatment records and an identification of any relevant treatment records
available at a Federal facility, such as a VA medical center, that support your claim
Any and all Service Treatment and Personnel Records in the custody of the veteran's Guard or Reserve Unit(s)
If claiming DIC as the parent of the veteran, all necessary income and net-worth information and, if claiming
benefits as the foster parent of the veteran, a completed VA Form 21-524, Statement of Person Claiming to Have
Stood in Relation of Parent
If claiming DIC with increased survivor benefits, a completed VA Form 21-2680, Examination for
Housebound Status or Permanent Need for Regular Aid and Attendance, and a completed VA Form 21-0779,
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
(This notice is applicable to survivors claims for: Death Pension • Dependency Indemnity Compensation (DIC) • DIC under 38
U.S.C. 1151 • Increased Survivor Benefits Based on Need for Aid and Attendance or Being Housebound • Accrued Benefits •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for DIC, Death Pension, and/or Accrued Benefits.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and
there is no risk to participate! To participate in the FDC Program if you are making a claim for DIC, Death Pension, and/or Accrued
Benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans
disability compensation or related compensation benefits, use VA Form 21-526EZ, Application for Disability Compensation and Related
Compensation Benefits. If you are making a claim for veterans non service-connected pension benefits, use VA Form 21-527EZ,
Application for Pension. VA forms are available at www.va.gov/vaforms.
NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION, AND/OR
ACCRUED BENEFITS
VA FORM
JUN 2014
21-534EZ
Page 1
.
Under the circumstances shown below, you must also submit simultaneously with your claim:
If claiming benefits as the surviving spouse of the veteran, a copy of your marriage certificate showing
your marriage to the veteran, or if claiming benefits for a child or biological/adoptive parent of the
veteran, a copy of the birth certificate or court record of adoption showing relation to the veteran
If claiming benefits for a child of the veteran between the ages of 18 and 23, a completed
VA Form 21-674, Request for Approval of School Attendance
If claiming benefits for a seriously disabled (helpless) child of the veteran, all, if any, relevant,
private medical treatment records for the child's pertinent disabilities
.
.
.
.
.
.
.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
SUPERSEDES VA FORM 21-534EZ, DEC 2012,
WHICH WILL NOT BE USED.
You must:
• Submit your claim in accordance with the
"FDC Criteria" (see page 1)
You must:
• If you know of evidence not in your possession and want
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are entitled.
If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your claim, then
VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard Claim Process. See
below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited Process). If you
wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession. If your claim involves a disability the veteran had before entering service and that was made worse by
service, please provide any information or evidence in your possession regarding the health condition that existed before the veteran's
entry into service.
VA FORM 21-534EZ, JUN 2014
Page 2
FDC Program (Optional Expedited Process)
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
Standard Claim Process
VA will:
• Retrieve relevant records from a Federal facility, such as
a VA medical center, that you adequately identify and
authorize VA to obtain
VA will:
• Retrieve relevant records from a Federal facility that you
adequately identify and authorize VA to obtain
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from state or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers
FDC Program (Optional Expedited Process)
Standard Claim Process
WHEN YOU SHOULD SEND WHAT WE NEED
You must:
• Send the information and evidence simultaneously with
your claim
If you submit additional information or evidence after you
submit your "fully developed" claim, then VA will remove the
claim from the FDC Program expedited process and process
it in the Standard Claim process. If we decide your claim before
one year from the date we receive the claim, you will still have
the remainder of the one-year period to submit additional
information or evidence necessary to support the claim.
FDC Program (Optional Expedited Process)
Standard Claim Process
We strongly encourage you to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to
submit the information and evidence necessary to support your
claim. If we decide the claim before one year from the date we
receive the claim, you will still have the remainder of the
one year period to submit additional information or evidence
necessary to support the claim.
WHERE TO SEND INFORMATION AND EVIDENCE
Mail or take your application and any evidence in support of your claim to the closest VA regional office. VA regional office
addresses are available on the Internet at www.va.gov/directory
.
Dependency and Indemnity Compensation (DIC)
To support a claim for Dependency and Indemnity Compensation (DIC) benefits based on a service-connected disability
established during the veteran's lifetime, the evidence must show:
• The veteran died while on active service; OR
• The veteran had a service-connected disability(ies) that was either the principal or contributory cause of
the veteran's death; OR
• The veteran died from non service-connected injury or disease AND was receiving, or entitled to receive VA
compensation for a service-connected disability rated totally disabling:
• For at least 10 years immediately before death; OR
• For at least 5 years after the veteran's release from active duty preceding death; OR
• For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999
Needs-based benefits based on the veterans wartime service.
You are eligible to the benefits because a child of the veteran is
severely disabled.
You are eligible to the benefits that were due to the veteran at
the time of the veteran's death.
Increased death pension or DIC benefits because your disabilities
cause you to be in need of aid and attendance or to be confined
to your residence.
DIC and it was previously denied by VA.
The veteran's death was a result of VA medical treatment,
vocational rehabilitation, or compensated work therapy.
• DIC benefits because the veteran was receiving or entitled to
receive benefits for a service-connected disability rated totally
disabling.
• The veteran's death was related to his or her service (DIC), OR
If you are claiming...
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
See the evidence table titled...
Death Pension
To support your claim for death pension benefits, the evidence must show:
1. The veteran met certain minimum requirements regarding active service during a period of war.
Generally, those requirements involve:
• 90 days of consecutive service, at least one day of which was during a period of war; OR
• 90 days of combined service during at least one period of war;
(Note : If the veteran's service began after September 7, 1980, additional length-of-service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligations.)
OR any length of active service during a period of war when:
• At the time of death, the veteran was receiving (or entitled to receive) VA disability compensation or
retirement pay for a service-connected disability; OR
• The veteran was discharged from active service due to a service-connected disability.
2. Your net worth and income do not exceed certain requirements.
Death Pension
To support a claim for DIC benefits based on a disability that was not service-connected or for which the veteran did not file
a claim during his or her lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active service, or an event in service that caused an injury
or disease; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by
medical evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in service. This may
be shown by medical records or medical opinion or, in certain cases, by lay evidence
VA FORM 21-534EZ, JUN 2014
Page 3
EVIDENCE TABLES
Dependency and Indemnity Compensation (DIC)
DIC under 38 U.S.C. 1151
Increased Survivor Benefits Based on Need for Aid and
Attendance or Being Housebound
Accrued Benefits
Helpless Child
Reopened DIC
In order to reopen a claim previously denied by VA, we need new and material evidence. New and material evidence must raise
a reasonable possibility of substantiating your claim. The evidence cannot simply be repetitive or cumulative of the evidence we
had when we previously decided your claim. VA will make reasonable efforts to help you obtain currently existing evidence.
However, we cannot provide a medical examination or obtain a medical opinion until your claim is successfully reopened.
• To qualify as new, the evidence must currently exist and be submitted to VA for the first time
• In order to be considered material, the additional existing evidence must pertain to the reason
your claim was previously denied
Dependency and Indemnity Compensation (DIC) (Continued)
To support your claim for DIC benefits based upon the service person's active duty for training, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty, and
the disease or injury caused or contributed to the service person's death.
If VA granted service connection for a disease or injury during the service person's lifetime, evidence that the service-connected
disease or injury caused or contributed to the service person's death may satisfy this requirement.
To support a claim for DIC benefits based on a disability that was not service-connected or for which the service person
did not file a claim during his or her lifetime, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by medical
evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the principal or contributory cause of death and the disability due to injury or disease, incurred in
the line of duty. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.
To support your claim for DIC benefits based upon the service person's inactive duty training, the evidence must show:
• The service person died during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute
myocardial infarction, cardiac arrest, or cerebrovascular accident during such training; OR
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty,
or acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; and that
injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's
death
If VA granted service connection for an injury, acute myocardial infarction, or cerebrovascular accident during the service person's
lifetime, evidence that the service-connected condition caused or contributed to the service person's death may satisfy this requirement.
To support a claim for DIC benefits based on a disability that was not service-connected or for which the service person did not
file a claim during his or her lifetime, the evidence must show:
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or
acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; AND
• The injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service
person's death
In order to support your claim for DIC under 38 U.S.C. 1151, the evidence must show:
• The deceased veteran died as a result of undergoing VA hospitalization, medical or surgical treatment,
examination, or training; AND
• The death was:
• the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment; OR
• the direct result of an event that was not a reasonably expected result or complication of the VA care or treatment; OR
• the direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program
EVIDENCE TABLES (Continued)
VA FORM 21-534EZ, JUN 2014
Page 4
DIC under 38 U.S.C. 1151:
Reopened DIC:
To support a claim for benefits based on a veteran's child being helpless, the evidence must show that the child, before his
or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.
To support a claim for accrued benefits, the evidence must show:
• Benefits were due the veteran based on existing ratings, decisions, or evidence in VA's possession at the
time of death, but the benefits were not paid before the veteran's death; AND
• You are the surviving spouse, child, or dependent parent of the deceased veteran
VA pays accrued benefits in the following order of priority:
1. Spouse
2. Children of the veteran (in equal shares)
3. Dependent parents (in equal shares)
In order to support your claim for increased survivor benefits based on the need for aid and attendance, the evidence must
show:
• you have corrected vision of 5/200 or less in both eyes; OR
• you have concentric contraction of the visual field to 5 degrees; OR
• you are a patient in a nursing home due to mental or physical incapacity; OR
• you require the aid of another person in order to perform personal functions required in everyday living, such as
bathing, feeding, dressing yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting
yourself from the hazards of your daily environment (38 Code of Federal Regulation 3.352(a)); OR
• you are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed
course of convalescence or treatment (38 Code of Federal Regulation 3.352(a)); OR
In order to support your claim for increased benefits based on being housebound, the evidence must show:
• you are substantially confined to your immediate premises because of permanent disability
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/.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/
For more
information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 1-800-829-4833.
VA forms are available at www.va.gov/vaforms.
VA FORM 21-534EZ, JUN 2014
Page 5
EVIDENCE TABLES (Continued)
HOW VA DETERMINES THE EFFECTIVE DATE
If we grant a claim for death benefits, the beginning date of your entitlement will generally be based on when we received your claim
However, if VA received your claim within one year of the date of the veteran's death, entitlement will be from the first day of the
month in which the veteran died.
The veteran's death certificate is evidence relevant to determining the effective date of any benefits we award.
Higher levels of benefits are available for a veteran's surviving spouse and/or parents who are unable to perform certain activities of
daily living or leave their home. Higher levels of benefits may be effective from the date medical evidence first establishes
entitlement.
Dependency and Indemnity Compensation (DIC) (Continued)
Helpless Child:
Accrued Benefits:
14B. YOUR TELEPHONE NUMBER(S) (include Area Code)
10. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
18E. PLACE OF LAST SEPARATION
ACCRUED BENEFITS
3. VETERAN'S DATE OF BIRTH
(MM,DD,YYYY)
DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
2. VETERAN'S SOCIAL SECURITY NUMBER
APPLICATION FOR DIC, DEATH PENSION,
AND/OR ACCRUED BENEFITS
OMB Control No. 2900-0004
Respondent Burden: 25 minutes
Expiration Date: 1/31/2015
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 11 before completing the form.
SECTION I: PERSONAL INFORMATION (MUST COMPLETE)
14A. WHAT IS YOUR ADDRESS?
5. HAS THE VETERAN, SURVIVING SPOUSE, CHILD, OR PARENT EVER
FILED A CLAIM WITH VA?
(If "Yes," provide the file number in Item 6)
City State ZIP Code Country
Street address, rural route, or P.O. Box Apt. number
CELL PHONE
( )
EVENING
( )
( )
16. WHAT ARE YOU CLAIMING? (Check all that apply)
6. VA FILE NUMBER 4. VETERAN'S SEX
15B. YOUR ALTERNATE E-MAIL ADDRESS (If applicable)
( )
17A. DID THE VETERAN SERVE UNDER ANOTHER NAME? 17B. PLEASE LIST OTHER NAME(S) THE VETERAN SERVED UNDER:
19C. WHAT IS THE NAME AND ADDRESS OF THE VETERAN'S RESERVE/NATIONAL GUARD UNIT?
(If "No," skip to Item 18A)
18A. VETERAN ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
19A. WAS THE VETERAN ACTIVATED TO FEDERAL ACTIVE DUTY UNDER AUTHORITY OF
TITLE 10, U.S.C. (National Guard)?
19D. WHAT IS THE TELEPHONE NUMBER OF THE
RESERVE/NATIONAL GUARD UNIT?
(Include Area Code)
(If "Yes," answer Items 19B, 19C and 19D)
19B. DATE OF ACTIVATION (MM,DD,YYYY)
18C. RELEASE DATE FROM ACTIVE SERVICE
(MM,DD,YYYY)
18B. BRANCH OF SERVICE
18D. DID THE VETERAN SERVE IN A COMBAT ZONE SINCE 9-11-2001?
1. VETERAN'S NAME (Last, first, middle)
20B. DATES OF CONFINEMENT
20A. WAS THE VETERAN EVER A PRISONER OF WAR?
(If "No," skip to Section III)
7. DID THE VETERAN DIE WHILE ON ACTIVE DUTY? 8. WHAT IS THE VETERAN'S DATE OF DEATH? (MM,DD,YYYY)
(If "Yes," complete Item 20B)
9. WHAT IS YOUR NAME? (First, middle, last name)
Page 6
VA FORM
JUN 2014
21-534EZ
DAYTIME
SECTION II: VETERAN'S SERVICE INFORMATION (COMPLETE ONLY IF THE VETERAN WAS NOT RECEIVING VA COMPENSATION OR
PENSION BENEFITS AT THE TIME OF DEATH)
(Skip to Section III if the veteran was receiving VA compensation or pension benefits at the time of his or her death)
13. ARE YOU A VETERAN? 11. WHAT IS YOUR SOCIAL SECURITY NUMBER?
(If "Yes," complete Item 17B)
12. WHAT IS YOUR DATE OF BIRTH?
(MM,DD,YYYY)
15A. YOUR PREFERRED E-MAIL ADDRESS (If applicable)
DEATH PENSION
FROM: TO:
SURVIVING SPOUSE
PARENT CHILD CUSTODIAN FILING FOR CHILD
SUPERSEDES VA FORM 21-534EZ, DEC 2012,
WHICH WILL NOT BE USED.
NO
YES NO
YES NO
YES NO
YES
NOYES
MALE FEMALE YES NO
YES NO
22F. HOW MARRIAGE
TERMINATED
(death, divorce, marriage has not
been terminated)
22H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22E, PLEASE EXPLAIN:
SECTION IV: DEPENDENT CHILDREN (COMPLETE ONLY IF CLAIMING BENEFITS FOR A CHILD(REN) OF THE VETERAN)
(Skip to Section V if you are NOT claiming benefits for a child(ren) of the veteran)
SECTION III- MARITAL INFORMATION (COMPLETE ONLY IF CLAIMING BENEFITS AS
THE SURVIVING SPOUSE OF THE VETERAN)
(Skip to Section IV if you are NOT claiming benefits as the surviving spouse of the veteran)
21A. HOW MANY TIMES WAS THE VETERAN MARRIED (including marriage to you)?
22G. DATE (month, day, year)
and PLACE MARRIAGE
TERMINATED
(city/state or country)
(Check all that apply)
VA FORM 21-534EZ, JUN 2014
TELL US ABOUT YOUR MARRIAGES
23. WAS A CHILD BORN TO YOU AND THE VETERAN DURING YOUR MARRIAGE
OR PRIOR TO YOUR MARRIAGE?
22B. HOW MANY TIMES HAVE YOU BEEN MARRIED? (including your marriage to the
veteran)
(If "Yes," provide explanation):
22A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
Page 7
If claiming benefits as the surviving spouse or custodian filing for a child, in items 29A through 29D tell us about the children listed in Item 28A who do
not live with you.
21G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 21D, PLEASE EXPLAIN:
28G.
18-23 YEARS
OLD (in school)
29B. CHILD'S COMPLETE ADDRESS
(Number and street or rural route, city or P.O., city,
State, ZIP Code and country)
28C. SOCIAL
SECURITY
NUMBER
TELL US ABOUT THE VETERAN'S MARRIAGES
28D.
BIOLOGICAL
21B. DATE (month, day, year) and PLACE
OF MARRIAGE (city, state or country)
21F. DATE (month, day, year) and
PLACE MARRIAGE TERMINATED
(city/state or country)
21C. TO WHOM MARRIED
(first, middle, last name)
21D. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)
21E. HOW MARRIAGE
TERMINATED
(death, divorce)
24. ARE YOU EXPECTING THE BIRTH OF THE VETERAN'S CHILD?
26. WHAT WAS THE CAUSE OF SEPARATION? GIVE THE REASON, DATE(S) AND
DURATION OF THE SEPARATION (IF THE SEPARATION WAS BY COURT ORDER,
ATTACH A COPY OF THE ORDER)
27. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?
$
28H.
SERIOUSLY
DISABLED
28F.
STEPCHILD
28I.
CHILD
MARRIED
28J. CHILD
PREVIOUSLY
MARRIED
22C. DATE (month, day, year) and PLACE
OF MARRIAGE (city/state or country)
22D. TO WHOM MARRIED
(first, middle, last name)
22E. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)
28E.
ADOPTED
29A. NAME OF CHILD
(First, middle initial, last name)
28A. NAME OF CHILD
(First, middle initial, last name)
28B. DATE (month, day,
year) and PLACE OF
BIRTH
(city/state or country)
29D. MONTHLY AMOUNT YOU
CONTRIBUTE TO THE CHILD'S
SUPPORT
29C. NAME OF PERSON THE CHILD
LIVES WITH (If applicable)
$
$
(If "No," complete Item 26)
25. DID YOU LIVE CONTINUOUSLY WITH THE VETERAN FROM THE DATE
OF MARRIAGE TO THE DATE OF HIS/HER DEATH?
NO
YES NO YES NO
YES
NOYES
NOYES
SECTION V: VETERAN'S PARENT (COMPLETE ONLY IF CLAIMING BENEFITS AS THE PARENT OF VETERAN)
(Skip to Section VI if you are NOT claiming benefits as the parent of a veteran)
30B. IF YOUR MARRIAGE HAS ENDED, PLEASE SPECIFY THE DATE (month, day, year) AND HOW MARRIAGE ENDED (death, divorce)
30C. IF YOU ARE SEPARATED, 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)
31D. IS YOUR SPOUSE ALSO A VETERAN?
31A. WHAT IS YOUR SPOUSE'S NAME? (First, middle initial, last name)
(Skip to Item 32A if never married or no longer married)
VA FORM 21-534EZ, JUN 2014
SECTION VI: DIC (COMPLETE ONLY IF CLAIMING DEPENDENCY AND INDEMNITY COMPENSATION (DIC))
(Skip to Section VII if you are NOT claiming DIC)
Page 8
(MM DD YYYY) to ( MM DD YYYY)
B. ADDRESS
A. NAME AND LOCATION OF VA MEDICAL CENTER
35. WHAT BENEFIT ARE YOU CLAIMING?
32B. DATE(S) OF PARENTAL CONTROL (If veteran did not live in your household
continuously before age 18 provide the time period (dates) when he/she was
under your parental control)
36. LIST ANY VA MEDICAL CENTERS WHERE THE VETERAN RECEIVED TREATMENT PERTAINING TO YOUR CLAIM AND PROVIDE TREATMENT DATES:
A. NAME (FIRST, MIDDLE, LAST)
32A. WAS THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR
PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE AGE
OF MAJORITY (AGE 18 IN MOST STATES)?
B. DATE(S) OF TREATMENT
30A. WHAT IS YOUR MARITAL STATUS? (Check one)
31C. WHAT IS YOUR SPOUSE'S SOCIAL
SECURITY NUMBER?
(If "Yes," skip to Item 34)
(If "Yes," complete Item 31E)
33. NAME AND ADDRESS OF EACH PERSON WHO ASSUMED PARENTAL CONTROL OVER THE VETERAN OUTSIDE THE DATE(S) SHOWN IN ITEM 32B
(MM DD YYYY) to ( MM DD YYYY)
31E. WHAT IS YOUR SPOUSE'S VA FILE NUMBER? (If applicable)
31B. WHAT IS YOUR SPOUSE'S DATE
OF BIRTH? (MM,DD,YYYY)
32C. WHY WASN'T THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE
AGE OF MAJORITY? (Explain fully)
City State ZIP Code Country
A. NAME (FIRST, MIDDLE, LAST)
B. DATE OF DEATH (MM,DD,YYYY)
City State ZIP Code Country
Street address, rural route, or P.O. Box Apt. number
34. IF YOU ARE NOT THE BIOLOGICAL PARENT OF THE VETERAN, PROVIDE THE NAMES OF THE BIOLOGICAL PARENTS, IF DECEASED, PROVIDE THE DATE
OF DEATH.
Street address, rural route, or P.O. Box Apt. number
DIC
DIC under 38 U.S.C. 1151 (RARE)
YES NO
YES
MARRIED AND LIVE WITH
OTHER PARENT OF VETERAN
SEPARATED, MARRIED BUT
NOT LIVING WITH SPOUSE
DIVORCED WIDOWED NEVER MARRIED
MARRIED AND LIVE WITH SPOUSE WHO
IS NOT THE OTHER PARENT OF THE VETERAN
NO
VA FORM 21-534EZ, JUN 2014
39. EXPECTED INCOME - NEXT 12 MONTHS (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
SECTION X: MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES
(COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)
(Skip to Section XI if you are NOT claiming death pension or parents DIC)
38. GROSS MONTHLY INCOME (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
Report total monthly income for your household. Identify the specific income recipient for each income source, yourself or another person in your household,
as applicable. If you are the custodian filing for a child of the veteran, you must report your income and the child's income, if any.
SECTION VII: NET WORTH (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)
(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)
Page 9
BLACK LUNG
BENEFITS
PURPOSE
(Medicare deduction, nursing home costs,
burial expenses, etc.)
AMOUNT
$
GROSS WAGES AND
SALARY
SECTION VIII: GROSS MONTHLY INCOME (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)
(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)
PAID TO (Name of nursing home,
hospital, funeral home, etc.)
CASH/NON-INTEREST
BEARING BANK
ACCOUNTS
40. MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES
IRA'S, KEOGH PLANS,
ETC.
INTEREST-BEARING
BANK ACCOUNTS
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.
RELATIONSHIP OF PERSON
FOR WHOM EXPENSES PAID
(Spouse, child, etc.)
Report total net worth for your household. Identify the specific owner for each net worth source, yourself or another person in your household, as applicable.
If you are the custodian filing for a child of the veteran, you must report your net worth and the child's net worth, if any.
REAL PROPERTY
(Not your home, vehicle,
furniture, or clothing)
OTHER PROPERTY
(Provide source)
STOCKS, BONDS,
MUTUAL FUNDS, ETC.
SOURCE RECIPIENT SOURCE
$
$
TOTAL DIVIDENDS AND
INTEREST
AMOUNT RECIPIENT
OTHER PROPERTY
(Provide source)
37. NET WORTH (DO NOT LEAVE ANY ITEMS BLANK. If your household has no net worth in a particular source, write "0" or "none")
$
AMOUNT PAID BY YOU
DATE PAID
(mm/dd/yyyy)
$
U.S. CIVIL SERVICE
$
U.S. RAILROAD
RETIREMENT
GROSS WAGES AND
SALARY
OTHER (Provide source)
OTHER (Provide source)
OTHER INCOME EXPECTED
(Provide source)
$
$
$
$
OTHER (Provide source)
OTHER (Provide source)
$
OTHER INCOME EXPECTED
(Provide source)
OTHER INCOME EXPECTED
(Provide source)
SECTION IX: EXPECTED INCOME (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)
(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)
AMOUNT SOURCE RECIPIENT SOURCE
SUPPLEMENTAL SECURITY
INCOME (SSI)/PUBLIC
ASSISTANCE
SOCIAL SECURITY
AMOUNT RECIPIENT
$
$
SOCIAL SECURITY
SERVICE RETIREMENT/
SURVIVOR BENEFIT PLAN
(SBP) ANNUITY
$
Report expected total household 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 total household income for the 12 month period from the date you sign this application. Identify the specific income recipient for each income source,
yourself or another person in your household, as applicable. If you are the custodian filing for a child of the veteran, you must report your expected income
and the child's expected income, if any.
OWNER SOURCE AMOUNT OWNER SOURCE AMOUNT
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
SECTION XII: CLAIM CERTIFICATION AND SIGNATURE (MUST COMPLETE)
SECTION XIII: WITNESSES TO SIGNATURE (COMPLETE ONLY IF CLAIMANT SIGNED ITEM 45A WITH AN "X")
47B. PRINTED NAME AND ADDRESS OF WITNESS
PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation and/or pension benefits (38 U.S.C. 5101). The responses you submit are considered confidential
(38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including the routine
uses 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. The requested information is considered relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer
matching programs with other agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is required in order to obtain or retain benefits. 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. Social Security information: 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.
46A. SIGNATURE OF WITNESS (If claimant signed above using an "X")
47A. SIGNATURE OF WITNESS (If claimant signed above using an "X")
45B. DATE SIGNED
46B. PRINTED NAME AND ADDRESS OF WITNESS
45A. CLAIMANT'S SIGNATURE (REQUIRED)
VA FORM 21-534EZ, JUN 2014
RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code, allows us to ask for this information. We estimate that you will
need an average of 25 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.
41. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
The Department of Treasury requires all Federal benefit payments 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, you must receive your payment through Direct Express Debit MasterCard. To request a Direct
Express Debit MasterCard you must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you
must contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will encourage your
participation in EFT and address any questions or concerns you may have.
43. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)
42. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)
Page 10
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.
I DO NOT want my claim considered for rapid processing under the FDC Program because I plan to submit further
evidence in support of my claim.
44. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide
the claim. VA will automatically consider a claim submitted on this form for rapid processing under the FDC Program. Check the box
below ONLY if you DO NOT want your claim considered for rapid processing under the FDC Program because you plan to submit
further evidence in support of your claim.
I certify I have enclosed all information or evidence that will support my claim, to include an identification of relevant records available
at a Federal facility, such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have
checked the box in Item 44, indicating that I do not want my claim considered for rapid processing in the Fully Developed Claim (FDC)
Program because I plan to submit further evidence in support of my claim.
I certify I have received the notice attached to this application titled Notice to Survivor of Evidence Necessary to Substantiate a Claim
for Dependency Indemnity Compensation, Death Pension, and/or Accrued Benefits.
SECTION XI: DIRECT DEPOSIT INFORMATION
(MUST COMPLETE)
Account No.:
CHECKING
SAVINGS
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A
FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT
Account No.:
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NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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Completed 13 February 2021

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