Fillable VBA 21 686c ARE 21 686c (U.S. Department of Veterans Affairs)

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VBA 21 686c ARE 21 686c (U.S. Department of Veterans Affairs)

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Page 1
NOTICE TO BENEFICIARY/CLAIMANT REGARDING THE INFORMATION AND EVIDENCE NEEDED TO
SUPPORT A CLAIM FOR ADDITIONAL BENEFITS FOR A DEPENDENT OR TO REMOVE A
DEPENDENT FROM AN AWARD
Use this form and the attached application to:
• submit a claim for additional benefits for a dependent, or
• request removal of a dependent from your award.
The table below identifies the types of dependents for whom VA beneficiaries may be entitled to additional benefits.
If you are a … Then you may be entitled to additional benefits for …
veteran entitled to disability compensation who has a
combined disability rating of at least 30 percent
• a spouse,
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school,
• children over age 18 that are permanently incapable of self-support, and/or
• dependent parents.
veteran entitled to Veterans Pension • a spouse,
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school, and/or
• children over age 18 that are permanently incapable of self-support
surviving spouse entitled to survivors benefits
• children under age 18,
• children that are between the ages of 18 and 23 who are attending school, and/or
• children over age 18 that are permanently incapable of self-support.
Exception: A surviving spouse entitled to Dependency and Indemnity Compensation (DIC) is
not entitled to additional benefits for children over age 18 that receive DIC in their own right.
TABLE OF CONTENTS
The table below provides a guide to the instructions and the application. The completion of certain sections of this application are
required. Be aware that you must complete Section I - Veteran/Claimant's Identification Information and Section X - Beneficiary/
Claimant's Certification and Signature. If these sections are not complete, we will not be able to process your claim for additional
benefits for dependents. Otherwise, complete the remaining sections that apply to you.
If you are …
Instructions Application
claiming additional benefits for a spouse Pages 3 and 4 Pages 8 and 9
claiming additional benefits for a child Pages 4 - 5 Pages 10 and 11
reporting a divorce Page 5 Page 12
reporting that a stepchild is no longer a member of your
household
Page 6
Page 12 and 13
reporting the death of a
• spouse
• child
• dependent parent
Page 5
Page 6
Page 6
Page 13
reporting the marriage of a child Page 6 Page 13
reporting that a schoolchild over 18 has stopped attending school Page 6 Page 13
claiming additional benefits for more than four children Addendum - Page 15
CIRCUMSTANCES THAT REQUIRE ADDITIONAL FORMS
Under certain circumstances, other forms in addition to VA Form 21-686c, Application Request to Add and/or Remove Dependents,
must be provided when claiming additional benefits for a dependent. The table below describes those circumstances. All VA forms
are available at www.va.gov/vaforms.
VA FORM 21-686c, SEP 2018
Page 2
If ... Then submit ...
• you are seeking additional benefits for a child or
children who are between the ages of 18 and 23
who are attending school
VA Form 21-674, Request for Approval of School Attendance.
Note: Submit VA Form 21-686c in addition to VA Form 21-674 only if you
have never received additional benefits for the child or children.
• you are entitled to Veterans Pension (instead of
disability compensation based on service-
connected disabilities), and
• you are seeking additional benefits for a spouse
only
submit VA Form 21P-0516-1, Improved Pension Eligibility Verification
Report (Veteran With No Children), in addition to VA Form 21-686c.
• you are entitled to Veterans Pension
• you are seeking additional benefits for a child or
children (with or without a spouse), and
• the child or children are under the age of 23 or
permanently incapable of self-support
VA Form 21P-0517-1, Improved Pension Eligibility Verification Report
(Veteran With Children), in addition to VA Form 21-686c.
• you are entitled to Survivors Pension,(instead of
DIC based on a veteran's service-connected death)
and
• you are seeking additional benefits for a child or
children that are either under the age of 23 or
incapable of self-support.
VA Form 21P-0519s-1, Improved Pension Eligibility Verification Report
(Surviving Spouse With Children), in addition to VA Form 21-686c.
• you are a veteran entitled to disability
compensation (based on service-connected
disabilities), and
• you are seeking additional benefits for a
dependent parent or parents.
VA Form 21P-509, Statement of Dependency of Parent(s).
Note: There is no need to submit VA Form 21-686c when filing a claim for
additional benefits for a dependent parent or parents.
• you are a veteran entitled to disability
compensation, and
• you are seeking additional benefits for a spouse
who requires aid and attendance
VA Form 21-2680, Examination for Housebound Status or Permanent Need
for Regular Aid and Attendance, or if your spouse resides in a nursing home,
use VA Form 21-0779, Request for Nursing Home Information in
Connection with Claim for Aid and Attendance.
Note: Submit VA Form 21-686c in addition to one of the forms referenced
above only if you have never received additional benefits for your spouse.
• you are a veteran seeking additional benefits for
a spouse based on common-law marriage
VA Form 21-4170, Statement of Marital Relationship, and
VA Form 21P-4171, Supporting Statement Regarding Marriage.
Note: The above referenced forms must be submitted in addition to
VA Form 21-686c.
Want to apply electronically? You can apply online at www.va.gov. If you sign in or create an account at www.va.gov, we can prefill
parts of your application and save your work in progress.
NOTE: You may wish to contact an accredited veteran service officer (VSO) to assist you with your application. You may locate a list of
VSO's at https://www.va.gov/vso/ .
HOW TO APPLY ELECTRONICALLY
WHERE TO SEND INFORMATION AND EVIDENCE
MAIL TO: FAX TO: ONLINE:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
844-531-7818 (toll free)
248-524-4260 (foreign claims)
www.va.gov
VA FORM 21-686c, SEP 2018
IMPORTANT: Applicants must provide their Social Security Number (SSN), and the SSN of their dependent(s) unless a SSN has not been assigned.
Use Section IX, Item 25, Remarks, to explain why a SSN has not been assigned.
TO ADD A SPOUSE TO A VETERAN'S AWARD:
Marriage by Ceremony
VA will require additional evidence* to establish a spouse; if
• you do not reside within a state, territory, or other possession of the United States,
• your entries on the application conflict with other information you provided, and the discrepancies
cannot be resolved through contact with you or a review of other information of record
• information of record raises questions regarding the validity of the marriage, or
• there is an indication of fraud or misrepresentation.
*Additional Evidence:
• Primary evidence of a marriage consists of a copy or abstract of the public record of a marriage, or a copy of the church
record of a marriage, containing sufficient data to identify the
• parties involved,
• date (month, day, and year) and place (city and state, county and state, or city and country) of the marriage, and
• number of prior marriages for each spouse, if not shown on the official record.
• If primary evidence of a marriage is unavailable, a marriage may still be established by submission of the following
evidence in the order of preference shown below;
• an official report from your branch of service regarding a marriage that occurred while you were in service,
• an affidavit of the clergyman or magistrate who officiated in the marriage ceremony,
• a certified copy of the original certificate of marriage,
• affidavits or certified statements signed by two or more witnesses that attended the marriage ceremony, or
• any other secondary evidence that reasonably supports the assertion that a valid marriage occurred.
Note: The process to establish a same sex or transgender marriage is no different than the process to establish a marriage between
the opposite sex.
Establishing a Common-Law Marriage
In some states it is possible to contract a marriage without a ceremony and without registration of the marriage. This type of marriage is
referred to as a common-law marriage.
VA may recognize a common-law marriage that was considered valid in the state in which it took place. A common law marriage
generally requires an agreement between the parties to be married, cohabitation, and holding themselves out to the public as married.
Evidence that must be submitted to claim a common-law marriage:
• VA Form 21-4170 completed by the veteran
• VA Form 21-4170 completed by the veteran's spouse in the common-law marriage
• Two VA Forms 21P-4171, each completed by two different persons that can provide their personal observations
about the parties to the common-law marriage and the relationship that exists/existed between them, and
• Copies of the birth certificates of any children born of the common-law marriage.
Tribal Ceremony
VA may recognize marriages performed in accordance with tribal custom.
To establish a tribal marriage, a claimant must provide all of the following items:
• Affidavits from the parties married by tribal custom that include the name of the tribe, date (month, day, and year) of marriage,
place (city and state, county and state, or city and country) where the marriage ceremony occurred, and name/mailing address of
the person who performed the ceremony.
• Affidavits from at least two people who were present at the time the tribal marriage ceremony took place. The affidavits must
include the name of the tribe, date (month, day, and year) of marriage, place (city and state, county and state, or city and country)
where the marriage ceremony occurred, and name/mailing address of the person who performed the ceremony.
• Affidavit from the person who performed the ceremony, showing the date (month, day, and year) and place (city and state,
county and state, or city and country) where the marriage ceremony occurred, and that person's authority for conducting the
ceremony.
Page 3
VA FORM 21-686c, SEP 2018
Page 4
Proxy Marriage
A proxy marriage is a wedding in which one or both of the individuals being united are not physically present, and are instead
represented by other persons. If both partners are absent, a double proxy wedding occurs.
Marriage by proxy typically occurs when a couple wishes to marry, but one or both partners cannot attend for reasons such as military
service, imprisonment, or travel restrictions; or when a couple lives in a jurisdiction in which they cannot legally marry.
All documents/certificates issued in connection with a claimed proxy marriage must be provided to establish a proxy marriage for VA
purposes.
Note: The validity of a proxy marriage is dependent upon the law in effect at the location in which the proxy marriage was performed.
Spousal Aid & Attendance (A&A)
• VA may pay additional benefits to a Veteran for a spouse with severe medical need/disability (ies). To claim the additional
benefits, a
• Veteran must complete a VA Form 21-2680 and submit medical evidence showing his or her spouse
• is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes or concentric contraction of the visual
field to 5 degrees or less; or
• is a patient in a nursing home because of mental or physical incapacity (by completing VA Form 21-0779); or
• requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding,
dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her
daily environment.
TO ADD A CHILD TO A BENEFICIARY/CLAIMANT'S AWARD:
Unmarried Child
A person must be unmarried in order to be considered a child for VA purposes.
VA may continue paying additional benefits for an unmarried child
• until the child reaches age
o 18, or
o 23, if the child is attending an approved school, or
• indefinitely if the child becomes permanently incapable of self-support before his/her 18
th birthday.
VA will require a copy of the child's birth certificate; if
• you do not reside within a state, territory or other possession of the United States,
• your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through
contact with you or a review of other information of record, or
• there is an indication of fraud or misrepresentation.
School-Age Child
You must complete and submit VA Form 21-674 to claim additional benefits for a child who is
• between the ages of 18 and 23, and
• attending school.
Note:
• Claimants with more than one school-age child must complete a separate VA Form 21-674 for each child.
• VA Form 21-674 is used to report
o school attendance,
o a change in the educational facility a child is attending, and/or
o a change in the date a school-age child plans to stop attending school.
Stepchild
VA will ask you to provide a copy of your stepchild's birth certificate, showing the names of both parents, before it will add the
stepchild; if
• you do not reside within a state, territory, or other possession of the United States,
• your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through
contact with you or a review of other information of record.
VA FORM 21-686c, SEP 2018
Page 5
• information of record raises questions regarding the validity of the marriage of the stepchild's biological or adoptive parent to
the veteran, or
• there is an indication of fraud or misrepresentation.
Provide a copy of the decree of adoption or adoptive placement agreement if the veteran's spouse is the adoptive parent of the
stepchild.
Note:
• VA may pay benefits to or for a stepchild only if the stepchild is (or was at the time of the veteran's death, if the veteran is
deceased) a member of the veteran's household.
• If the veteran and stepchild do not reside together (or were not residing together when the veteran died, if the veteran is
deceased), the stepchild remains a member of the veteran's household if
• they live (or lived, if the veteran is deceased) apart for medical reasons, to attend school, or to fulfill a military service
obligation, or
• the veteran provides (or provided, if the veteran is deceased) at least half of the stepchild's support.
Adopted Child
A claim for additional benefits for an adopted child must include a copy of the
• final decree of adoption,
• adoptive placement agreement,
• interlocutory decree of adoptions, or
• revised birth certificate.
Note: VA cannot pay additional benefits for a grandchild or foster child unless the claimant submits evidence (referenced above)
showing the veteran adopted the grand/foster child.
Child Incapable of Self-Support
VA may pay additional benefits for a child beyond his/her 23rd birthday if VA determines the child became permanently incapable of
self-support before his/her 18th birthday.
A claim for additional benefits for a child who is incapable of self-support must include
• medical evidence showing a permanent mental or physical disability existed before his/her 18th birthday, and
• a statement from an attending physician showing the nature and extent of the child's physical or mental impairment.
REMOVAL OF A SPOUSE FROM A VETERAN'S AWARD:
Divorce or Death of a Spouse
VA FORM 21-686c, SEP 2018
VA must remove a spouse from a veteran's award when the spouse dies or divorces/annuls the marriage to the veteran.
Note:
• Veterans in receipt of disability compensation are not required to report to VA a separation or estrangement from their spouse,
as it will have no effect on their award.
• Veterans remain entitled to additional benefits for a stepchild after divorcing the stepchild's biological or adoptive parent, as
long as the veteran provides at least half of the stepchild's support.
Page 6
REMOVAL OF A CHILD FROM A BENEFICIARY'S AWARD:
Married Child
A person must be unmarried to qualify as a child for VA purposes. Therefore, a person of any age who marries ceases to be a child for
VA purposes.
Note: If a child marries, and then the marriage is terminated by annulment or declared void, VA may resume the payment of additional
benefits for the child.
Child Who Is Between the Ages of 18 and 23 and Not Attending School
To be considered a school child for VA purposes a person must be between the ages of 18 and 23 and attending a VA-accredited
educational facility.
Stepchild
VA must remove a stepchild from a veteran's award when the stepchild ceases being a member of the veteran's household.
Note: The awarding of legal custody of a stepchild to someone other than the veteran will not affect the additional benefits to which the
veteran is entitled for that child, as long as the stepchild remains a member of the veteran's household.
Child Given Up for Adoption
In most cases, a beneficiary who gives up a child for adoption is no longer entitled to additional benefits for that child.
VA will use the most beneficial effective date when removing the veteran's child that has been given up for adoption. The date (month,
day, and year) that the child was given up for adoption must be provided. Use Section IX, Item 25, Remarks to provide this information.
Death of a Child
VA must remove a child from a beneficiary's award when the child dies.
REMOVAL OF A DEPENDENT PARENT DUE TO DEATH:
Dependent Parent
VA must remove a dependent parent from a veteran's award when a parent dies.
For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.com/, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
VA FORM 21-686c, SEP 2018
APPLICATION REQUEST TO ADD AND/OR
REMOVE DEPENDENTS
INSTRUCTIONS: Make sure you sign and date this form in Items 26A and 26B.
Note: Unless the claimant is the veteran's surviving spouse or a designated "alternate
signer", the veteran must sign in Item 26A. When you have completed this form,
you can mail or fax it to the address or the fax number shown at the bottom of Page 2.
If you prefer you may complete and submit the form online at www.va.gov.
VA FORM
SEP 2018
21-686c
OMB Approved No. 2900-0043
Respondent Burden: 30 minutes
Expiration Date: 09/30/2021
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
SECTION I: VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION
(Note: Completion of this section is REQUIRED to process your request; any omission may delay processing)
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to help expedite processing of the form.
4. VETERAN'S DATE OF BIRTH (MM-DD-YYYY)
3. VA FILE NUMBER (If known)
2. VETERAN'S SOCIAL SECURITY NUMBER
1. VETERAN'S NAME (First, Middle Initial, Last)
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
10. COMPLETE MAILING ADDRESS OF VETERAN/CLAIMANT
(Number and Street or Rural Route, P. O. Box, City, State, ZIP Code and Country)
SECTION II: INFORMATION NEEDED TO ADD SPOUSE
11A. SPOUSE'S NAME (First, Middle Initial, Last)
5. CLAIMANT'S NAME (If other than veteran) (First, Middle Initial, Last)
6. CLAIMANT'S SOCIAL SECURITY NUMBER
7. VETERAN'S SERVICE NUMBER (If applicable)
8. TELEPHONE NUMBER (Include Area Code)
9. E-MAIL ADDRESS (Optional)
11B. SPOUSE'S DATE OF BIRTH
11C. SPOUSE'S SOCIAL SECURITY NUMBER (SSN) (If
your spouse does not have an SSN, explain why in Section
IX, Item 25, Remarks)
11D. DATE OF MARRIAGE
11E. PLACE OF MARRIAGE (City and State, County and State, or City and Country)
OTHER (Explain)
TRIBAL
PROXY
COMMON LAW
RELIGIOUS CEREMONY (i.e. Minister, Priest, Rabbi, etc.) or CIVIL CEREMONY (i.e. Justice of the Peace)
11F. HOW WERE YOU MARRIED? (Check one)
NO
YES (If "YES," complete Items 12B and 12C)
12A. IS YOUR SPOUSE ALSO A VETERAN?
12B. SPOUSE'S VA FILE NUMBER (If applicable)
12C. SPOUSE'S SERVICE NUMBER (If applicable)
SUPERSEDES VA FORM 21-686c, JUN 2017.
Page 7
NO (If "NO," complete Items 13B and 13C)
YES
13A. DO YOU LIVE TOGETHER?
13B. REASON FOR SEPARATION (For example, marital problems, job requirements, health, etc.)
13C. CURRENT MAILING ADDRESS OF SPOUSE (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
NOTE: If you are a veteran that VA is paying additional benefits for a stepchild and you no longer live with the stepchild's biological or adoptive parent, complete Section V.
Country
State/Province
City or County
NOTE: You must provide complete information about your prior marriages and your current spouse's prior marriages.
VETERAN/CLAIMANT'S PREVIOUS MARITAL INFORMATION
(If no prior marriages, this section may be left blank)
VA FORM 21-686c, SEP 2018
VETERAN'S SOCIAL SECURITY NO.
Page 8
14A.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
14A.3 REASON FOR TERMINATION
14A.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
14A.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Annulment
Divorce
Death
Other:
Country
State/Province
City or County
14B.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
14B.3 REASON FOR TERMINATION
14B.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
14B.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Annulment
Divorce
Death
Other:
Country
State/Province
City or County
14C.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
14C.3 REASON FOR TERMINATION
14C.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
14C.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Annulment
Divorce
Death
Other:
Country
State/Province
City or County
Country
State/Province
City or County
14D.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
14D.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
Other:
Annulment
Divorce
Death
14D.3 REASON FOR TERMINATION
14D.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
CURRENT SPOUSE'S PREVIOUS MARITAL INFORMATION
(If no prior marriages, this section may be left blank)
15A.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
VA FORM 21-686c, SEP 2018
VETERAN'S SOCIAL SECURITY NO.
Page 9
15A.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Country
State/Province
City or County
15A.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
Other:
Annulment
Divorce
Death
15A.3 REASON FOR TERMINATION
15B.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Other:
Annulment
Divorce
Death
15B.3 REASON FOR TERMINATION
15B.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
15B.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
Country
State/Province
City or County
Country
State/Province
City or County
15C.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
15C.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Country
State/Province
City or County
15C.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
Other:
Annulment
Divorce
Death
15C.3 REASON FOR TERMINATION
15D.2 DATE AND PLACE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
Other:
Annulment
Divorce
Death
15D.3 REASON FOR TERMINATION
15D.1 TO WHOM MARRIED (First, Middle Initial, Last Name)
15D.4 DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)
YES (If "Yes," provide the date the child entered veteran's household)
VA FORM 21-686c, SEP 2018
SECTION III: INFORMATION NEEDED TO ADD CHILD(REN)
(If claiming more than four children, fill out addendum (Page 15) and submit with application)
VETERAN'S SOCIAL SECURITY NO.
Page 10
16A. NAME OF FIRST CHILD TO ADD (First, Middle Initial, Last)
16B. SOCIAL SECURITY NUMBER
16C. DATE OF BIRTH (MM-DD-YYYY)
16D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
16E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
16F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
16G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL
ADOPTED
STEPCHILD (If checked, complete Item 17I)
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)
OTHER (Explain)
ANNULLED
DECLARED VOID
16H. HOW AND WHEN MARRIAGE ENDED
16I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
ZIP Code/Postal Code
Country
State/Province
City
No. &
Street
Apt./Unit Number
Country
State/Province
City or County
DATE (MM-DD-YYYY)
DATE (MM-DD-YYYY)
Country
State/Province
City or County
YES (If "Yes," provide the date the child entered veteran's household)
17A. NAME OF SECOND CHILD TO ADD (First, Middle Initial, Last)
17B. SOCIAL SECURITY NUMBER
17C. DATE OF BIRTH (MM-DD-YYYY)
17D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
17E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
17F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
17G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL ADOPTED
STEPCHILD (If checked, complete Item 17I)
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)
OTHER (Explain)
ANNULLED
DECLARED VOID
17H. HOW AND WHEN MARRIAGE ENDED
17I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
ZIP Code/Postal Code
Country
State/Province
City
No. &
Street
Apt./Unit Number
Country
State/Province
City or County
DATE (MM-DD-YYYY)
DATE (MM-DD-YYYY)
VA FORM 21-686c, XXX XXXX
Page 11
YES (If "Yes," provide the date the child entered veteran's household):
19A. NAME OF FORTH CHILD TO ADD (First, Middle Initial, Last)
19B. SOCIAL SECURITY NUMBER
19C. DATE OF BIRTH (MM-DD-YYYY)
19D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
19E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
19F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
19G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL
ADOPTED
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 18H)
OTHER (Explain)
ANNULLED
DECLARED VOID
19H. HOW AND WHEN MARRIAGE ENDED
DATE (MM-DD-YYYY)
19I. IF YOU CHECKED "STEPCHILD" IN ITEM 18G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
STEPCHILD (If checked, complete Item 18I)
ZIP Code/Postal Code
Country
State/Province
City Apt./Unit Number
No. &
Street
DATE (MM-DD-YYYY)
Country
State/Province
City or County
YES (If "Yes," provide the date the child entered veteran's household)
18A. NAME OF THIRD CHILD TO ADD (First, Middle Initial, Last)
18B. SOCIAL SECURITY NUMBER
18C. DATE OF BIRTH (MM-DD-YYYY)
18D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
18E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
18F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
18G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL ADOPTED
STEPCHILD (If checked, complete Item 17I)
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)
OTHER (Explain)
ANNULLED
DECLARED VOID
18H. HOW AND WHEN MARRIAGE ENDED
18I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
ZIP Code/Postal Code
Country
State/Province
City
No. &
Street
Apt./Unit Number
Country
State/Province
City or County
DATE (MM-DD-YYYY)
DATE (MM-DD-YYYY)
SECTION III: INFORMATION NEEDED TO ADD CHILD(REN) Continued
(If claiming more than four children, fill out addendum (Page 15) and submit with application)
VETERAN'S SOCIAL SECURITY NO.
VA FORM 21-686c, SEP 2018
VETERAN'S SOCIAL SECURITY NO.
Page 12
SECTION IV: VETERAN REPORTING DIVORCE FROM FORMER SPOUSE
(If you have stepchild(ren), also complete Section V)
20A. NAME OF FORMER SPOUSE (First, Middle Initial, Last)
20B. PLACE OF DIVORCE (Provide city and state, county and state, or city and country)
20C. DATE OF DIVORCE
SECTION V: VETERAN/CLAIMANT REPORTING ON STEPCHILD(REN)
NO (If "NO," skip to Section VI)
YES (If "YES," list the name(s) of the stepchild(ren) here):
21A.1 DID YOU HAVE A STEPCHILD(REN) THAT WAS THE BIOLOGICAL OR ADOPTED CHILD(REN) OF THE FORMER SPOUSE LISTED IN ITEM 20A?
NO (If "NO," skip to Section VI)
YES (If "YES," complete Items 21C through 21L)
21B. ARE YOU STILL SUPPORTING YOUR STEPCHILD(REN) LISTED IN ITEM 21A?
21C. NAME OF STEPCHILD YOU ARE SUPPORTING
21D. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE THE NAME OF PERSON WITH WHOM STEPCHILD RESIDES
21E. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE A COMPLETE ADDRESS
21F. DATE STEPCHILD LEFT VETERAN'S HOUSEHOLD (MM-DD-YYYY)
21G. FINANCIAL SUPPORT PROVIDED
More than half
Half
Less than half
NOTE: If marriage ended as an annulment or declared void, use Section IX, Item 25, Remarks to explain.
Country
State/Province
City or County
21A.2 NAME(S) OF STEPCHILD(REN) (First, Middle Initial, Last)
ZIP Code/Postal Code
Country
State/Province
City Apt./Unit Number
No. &
Street
21H. NAME OF STEPCHILD YOU ARE SUPPORTING
21I. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE THE NAME OF PERSON WITH WHOM STEPCHILD RESIDES
21J. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE A COMPLETE ADDRESS
ZIP Code/Postal Code
Country
State/Province
City Apt./Unit Number
No. &
Street
VA FORM 21-686c, SEP 2018
Page 13
SECTION VI: VETERAN/CLAIMANT REPORTING DEATH OF A DEPENDENT
22A. DEPENDENT TYPE (Check all that apply)
ADOPTEDSTEPCHILDMINOR CHILD (UNDER 18 YEARS OLD
CHILD INCAPABLE OF SELF-SUPPORT
SPOUSE
18-23 YEARS OLD AND IN SCHOOL
DEPENDENT PARENT
22B. NAME OF DEPENDENT(First, Middle Initial, Last)
22C. DATE OF DEATH (MM/DD/YYYY)
22D. PLACE OF DEATH (City & State, County & State, or City & Country)
SECTION VII: VETERAN/CLAIMANT REPORTING MARRIAGE OF CHILD
23A. NAME OF CHILD (First, Middle Initial, Last)
23B. DATE OF MARRIAGE (MM-DD-YYYY)
Country
State/Province
City or County
21K. DATE STEPCHILD LEFT VETERAN'S HOUSEHOLD (MM-DD-YYYY)
21L. FINANCIAL SUPPORT PROVIDED
More than half
Half
Less than half
22A. DEPENDENT TYPE (Check all that apply)
ADOPTEDSTEPCHILDMINOR CHILD (UNDER 18 YEARS OLD
CHILD INCAPABLE OF SELF-SUPPORT
SPOUSE
18-23 YEARS OLD AND IN SCHOOL
DEPENDENT PARENT
22B. NAME OF DEPENDENT(S) (First, Middle Initial, Last)
22C. DATE OF DEATH (MM/DD/YYYY)
22D. PLACE OF DEATH (City & State, County & State, or City & Country)
Country
State/Province
City or County
VETERAN'S SOCIAL SECURITY NO.
24A. NAME OF SCHOOLCHILD (First, Middle Initial, Last)
24B. DATE SCHOOLCHILD STOPPED ATTENDING SCHOOL (MM-DD-YYYY)
SECTION VIII: VETERAN/CLAIMANT REPORTING A SCHOOLCHILD OVER 18 HAS STOPPED ATTENDING SCHOOL
VA FORM 21-686c, SEP 2018
VETERAN'S SOCIAL SECURITY NO.
Page 14
SECTION IX: REMARKS
IMPORTANT: The primary purpose of this form is to gather information or statements that may result in a change to your VA benefits. By
signing this form you have given permission to make benefit payment changes that could result in the creation of an overpayment. If such
adverse actions are taken you will receive additional notification from VA regarding repayment options.
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
26A. SIGNATURE OF BENEFICIARY/CLAIMANT OR ALTERNATE
SIGNER* (Please sign in ink)
26B. DATE (MM/DD/YYYY)
*ALTERNATE SIGNER: By signing on behalf of the beneficiary/claimant, I certify that the claimant is:
• under the age of 18,
• mentally incompetent to provide substantially accurate information needed to complete the form or to certify that the statements made on the
form are true and complete, or
• physically unable to sign the form
• a court-appointed representative,
• an attorney in fact or agent authorized to act on behalf of the claimant under a durable power of attorney,
• a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative, or
• a manager or principal officer acting on behalf of an institution which is responsible for the care of the claimant.
PRIVACY ACT INFORMATION: 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 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, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your and your dependents' SSN
account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 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.
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.
RESPONDENT BURDEN: We need this information to determine marital status and eligibility for an additional allowance for dependents under 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 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 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.
25. REMARKS (If any)
*ALTERNATE SIGNER: By signing on behalf of the beneficiary/claimant, I certify that I am:
SECTION X: BENEFICIARY/CLAIMANT'S CERTIFICATION AND SIGNATURE
(Note: Completion of this section is REQUIRED to process your request)
(FOR USE BY VA ONLY)
VETERAN'S SOCIAL SECURITY NO.
SECTION XI: ADDITIONAL CHILD(REN) (Addendum)
(Please submit this page with the completed application if you have additional children to add to your claim. If more space is
needed, please make additional copies of this page to submit with your application.)
VA FORM 21-686c, SEP 2018
PAGE 15 - Addendum
YES (If "Yes," provide the date the child entered veteran's household)
1A. NAME OF ADDITIONAL CHILD TO ADD (First, Middle Initial, Last)
1B. SOCIAL SECURITY NUMBER
1C. DATE OF BIRTH (MM-DD-YYYY)
1D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
1E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
1F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
1G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL ADOPTED
STEPCHILD (If checked, complete Item 17I)
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)
OTHER (Explain)
ANNULLED
DECLARED VOID
17H. HOW AND WHEN MARRIAGE ENDED
1I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
ZIP Code/Postal Code
Country
State/Province
City
No. &
Street
Apt./Unit Number
Country
State/Province
City or County
DATE (MM-DD-YYYY)
DATE (MM-DD-YYYY)
YES (If "Yes," provide the date the child entered veteran's household)
2A. NAME OFADDITIONAL CHILD TO ADD (First, Middle Initial, Last)
2B. SOCIAL SECURITY NUMBER
2C. DATE OF BIRTH (MM-DD-YYYY)
2D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)
2E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH
2F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES
2G. CHILD STATUS (Check all that apply)
CHILD INCAPABLE OF SELF-SUPPORT
BIOLOGICAL ADOPTED
STEPCHILD (If checked, complete Item 17I)
18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)
CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)
OTHER (Explain)
ANNULLED
DECLARED VOID
2H. HOW AND WHEN MARRIAGE ENDED
2I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
NO
ZIP Code/Postal Code
Country
State/Province
City
No. &
Street
Apt./Unit Number
Country
State/Province
City or County
DATE (MM-DD-YYYY)
DATE (MM-DD-YYYY)
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VBA 21 686c ARE 21 686c (U.S. Department of Veterans Affairs)

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Completed 18 July 2020

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