PRIVACY ACT NOTICE: 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 5, Code
of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological ore 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, Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. You must give us your and your dependents SSN account information. Applicants are
required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 5101 (c) (1). The 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 the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for an additional allowance for your spouse and/or child(ren). 38 U.S.C. 1115, Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 10 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. Valid OMB control numbers can be located on the OMB Internet page at
www.reginfo.gov/public/do/PRAMain If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
13. SIGNATURE OF VETERAN OR GUARDIAN
14. DATE SIGNED (MM/DD/YYYY)
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.
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
SIGN HERE
IN INK
12. REMARKS
Page 4
VA FORM 21-0538, DEC 2017
SECTION IV: VETERAN SIGNATURE
SECTION III: CHILD(REN) INFORMATION (Continued)
NOTE: Furnish the following information for each terminated dependent.
11A.2 PROVIDE REASON FOR TERMINATION
(Death, Divorce, Age)
11A.2 DATE OF TERMINATION (MM-DD-YYYY)
VETERAN'S SOCIAL SECURITY NO.
11A.1 DEPENDENT'S NAME (First, Middle Initial, Last)
11B.2 PROVIDE REASON FOR TERMINATION
(Death, Divorce, Age)
11B.3 DATE OF TERMINATION (MM-DD-YYYY)
11B.1 DEPENDENT'S NAME (First, Middle Initial, Last)
11C.2 PROVIDE REASON FOR TERMINATION
(Death, Divorce, Age)
11C.3 DATE OF TERMINATION (MM-DD-YYYY)
11C.1 DEPENDENT'S NAME (First, Middle Initial, Last)
11D.2 PROVIDE REASON FOR TERMINATION
(Death, Divorce, Age)
11D.3 DATE OF TERMINATION (MM-DD-YYYY)
11D.1 DEPENDENT'S NAME (First, Middle Initial, Last)
