Sections I and II: identification
The Veteran's name, Social Security number, VA file number, date of birth, service number and phone, then the spouse or surviving spouse's name, Social Security number and date of birth, and a mailing address.
21-4170
Statement of Marital Relationship
- Agency
- VA
- Revision
- August 2024
- Fillable fields
- 171
- Pages
- 5
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-4170: Statement of Marital Relationship
VA Form 21-4170 is the U.S. Department of Veterans Affairs Statement of Marital Relationship. The form's instructions say to use it to provide information to VA to determine your marital status. It says it is completed by the Veteran, if living, and the person who is claiming to be the spouse or surviving spouse of the Veteran.
The form asks when and where the two began living as marital partners, any periods of separation, the places they lived, children they had together and every marriage of each of them. It asks for documents showing that the two held themselves out as married or are generally accepted as married in the community where they live or lived, such as lease agreements, joint bank statements, utility bills, tax returns, insurance forms and employment records.
The PDF has five pages: the form on pages 1 to 4 and mailing information on page 5. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21-4170
Section III: the marital relationship claimed
The date and place you began living as marital partners, names used before that, whether the claimed spouse used the Veteran's last name, the agreed relationship, whether you lived together continuously, periods of separation and places lived.
Section IV: children
Whether you have had children together, and each child's full name and place of birth. The form asks for a certified copy of the public record of birth for each child listed.
Section V: marital history
Every marriage of the Veteran and of the spouse or surviving spouse: date and place of marriage, to whom, and the date, place and way it ended. The form asks for copies of divorce decrees.
Sections VI to VIII: remarks, signatures and witnesses
Room for remarks, the certification that the statements are true and correct, the required signatures of the Veteran and the claimed spouse or surviving spouse, and witness lines for a signature by mark.
Notices and mailing page
Page 4 has the penalty, Privacy Act and respondent burden notices, about 25 minutes. Page 5 lists where to send written correspondence.
How to complete VA Form 21-4170
- 1
Read the notices on page 4
The instructions say to read the Privacy Act and Respondent Burden on page 4 before completing the form.
- 2
Fill in each section together
Answer every item that applies. The form says to write "unknown" if you do not know an answer, and by hand to print neatly, one letter per box, and fill in each applicable check box.
- 3
Use remarks for more space
The form says to use Section VI, Remarks, when more space is needed, with the item number each answer applies to.
- 4
Gather supporting documents
Add documents that show marital status, birth records for children listed and copies of divorce decrees. The form says original documents will not be returned and encourages certified copies instead.
- 5
Sign, date and send it
Both signers sign and date Section VII. Page 5 says documents may be submitted by mail, in person at a VA regional office or electronically.
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Where to send it and getting help
Electronically
Page 5 says VA recommends submitting correspondence electronically as the fastest method of receipt, and points to www.va.gov/disability/upload-supporting-evidence and Direct Upload at access.va.gov.
Compensation claims by mail
Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
Pension and survivors benefit claims by mail
Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Page 5 also lists addresses for Fiduciary and the Board of Veterans' Appeals.
Questions
The form points to Ask VA at https://ask.va.gov and the toll-free number 1-800-827-1000. For TDD, the Federal relay number is 711.
Edition
The August 2024 edition supersedes the July 2021 edition. It carries OMB Control No. 2900-0114, which expires 8/31/2027.
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76 fields, 3 pages
Who completes VA Form 21-4170?
The form's important information box says who fills it in.
Official sources and the blank
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Questions about Form 21-4170
What is VA Form 21-4170 used for?
The form's instructions say to use it to provide information to VA to determine your marital status.
Who fills out VA Form 21-4170?
The form says it is completed by the Veteran, if living, and the person claiming to be the spouse or surviving spouse of the Veteran. Both sign Section VII.
Which documents does the form ask for?
Documents showing marital status, such as lease agreements, joint bank statements, utility bills, tax returns, insurance forms and employment records, plus a certified birth record for each child listed and copies of divorce decrees.
Will VA return original documents?
The form says original documents will not be returned and that VA highly encourages submitting certified copies instead.
What if I don't know an answer?
The form says to write "unknown" if you do not know the answer.
Where do I send VA Form 21-4170?
Page 5 says documents may be submitted by mail, in person at a VA regional office or electronically, and lists the Evidence Intake Center for compensation claims and the Pension Intake Center for pension and survivors benefit claims.