Form 21P-0537 Marital Status Questionnaire

In Reply Refer To:

You are receiving Dependency and Indemnity Compensation (D.I.C.) as the surviving spouse of a veteran
who died in service or from service-connected conditions. Generally, a surviving spouse's entitlement to
D.I.C. ends with remarriage. If a surviving spouse remarries, entitlement may continue provided the
marriage began after age 55 or has been terminated. You are responsible for reporting any change in your
marital status.
We need to verify your marital status. Please answer the questions below.
If you do not return this letter with your answers to VA within 60 days of the date shown above, we may
propose to terminate your D.I.C. benefits. After answering the questions below, please return this letter in
the enclosed envelope. Be sure to place it in the envelope so that the return address of the regional office
shows through the envelope window.
You have the right at any time to submit additional information or to have a personal hearing to explain or
clarify your statements. You also have the right to be represented at the hearing by a representative of
your choice.
If You Have Questions or Need Assistance
If you have any questions, you may contact us by telephone, e-mail, or letter.
If you:
Telephone

Here is what to do:
Call us at 1-800-827-1000. If you use a Telecommunications Device for the
Deaf (TDD), the number is 711.

Use the Internet

Send electronic federal inquiries through the Internet at https://www.va.gov.

Write

Put your full name and VA file number on the letter. Please send all
correspondence to the address at the top of this letter.

Sincerely yours,

Regional Office Director
Enclosure

VA FORM
XXX 20XX

21P-0537

OMB Approved No. 2900-0495
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/20XX

MARITAL STATUS QUESTIONNAIRE
PRIVACY ACT INFORMATION: Payment of survivor's benefits cannot be made unless the information requested is furnished as required by existing law (38 U.S.C. 101(3)). The
responses you submit are considered confidential, (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs only if the disclosure is authorized by the Privacy Act,
including the routine uses identified in the system of records, 58VA21/22/28, VA Compensation, Pension, Education, and Veteran Readiness 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. 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0495, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at vapra@va.gov. Please refer to OMB Control No. 2900-0495 in any correspondence. Do not send your completed VA Form 21P-0537 to this email address.
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/.
1B. DATE OF MARRIAGE (MM/DD/YYYY)

1A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
YES

NO

(If "Yes," please answer ALL questions 1-5; if "No," please skip to questions 3-5 only.)

Month

Day

Year

1C. NAME OF SPOUSE

1D. SPOUSE DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

1E. IS YOUR SPOUSE A
VETERAN?
YES

NO

1F. IF "YES," PROVIDE YOUR NEW SPOUSE'S VA FILE NUMBER OR SOCIAL
SECURITY NUMBER
VA CLAIM NO.
OR

1G. WHAT WAS YOUR AGE AT THE
TIME OF YOUR MARRIAGE?

SSN

2A. HAS YOUR REMARRIAGE BEEN TERMINATED?
YES

NO

2B. DATE OF TERMINATION (MM/DD/YYYY)
Month

Day

Year

(If "Yes," please provide the date in Item 2B and the reason
for termination (i.e., death, divorce) in Item 2C)
2C. REASON FOR TERMINATION

3A. DAYTIME TELEPHONE NUMBER (Include Area Code)

3B. EVENING TELEPHONE NUMBER (Include Area Code)

4. E-MAIL ADDRESS

5A. SIGNATURE (Sign in ink)

5B. DATE SIGNED (MM/DD/YYYY)
Month

VA FORM
XXX 20XX

21P-0537

Day

Year