Items 1 to 4: names and address
The Veteran or beneficiary's name, the Veteran's Social Security number and VA file number, the claimed spouse's name, and the name and address of the person completing the form.
21P-4171
Supporting Statement Regarding Marriage
- Agency
- VA
- Revision
- May 2024
- Fillable fields
- 108
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21P-4171: Supporting Statement Regarding Marriage
VA Form 21P-4171 is the U.S. Department of Veterans Affairs Supporting Statement Regarding Marriage. It is completed by a person who knows the Veteran and the claimed spouse or surviving spouse, and asks how they know the couple and whether the couple was known as married. The certification says the statement will be considered in connection with an application for VA benefits based on a marital relationship between the Veteran and the person named in Item 3.
The form is two pages. It covers how long and how often the person has known and visited the couple, whether they lived together, and any other marriages of either one. VA's form page lists it under pension and family member and caregiver benefits.
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 21P-4171
Items 5 to 7: how you know them
Your relationship to the Veteran and to the claimed spouse, how long you have known each, how often you visited and on what occasions.
Items 8 to 12: known as married
Whether the couple was generally known as married, whether either denied the marriage, whether you consider them married and why, names the spouse was known by, and when and where you heard them refer to each other as married.
Items 13 and 14: living together
Whether the couple kept a home and lived together as married, the periods and places with beginning and ending dates, city and state, and whether they lived together continuously.
Items 15 and 16: other marriages
Any other marriages of the Veteran or the claimed spouse: to whom, date and place, type of marriage, how it ended and the date and place it ended.
Remarks, certification and witnesses
Item 17 remarks, the certification with signature in ink, date and daytime and evening phone numbers in Item 18, and Items 19 and 20 for witnesses to a signature by mark.
How to fill out VA Form 21P-4171
- 1
Answer every item
The instructions ask that all items be completed and say to write unknown if you do not know the answer.
- 2
Describe how you know the couple
Fill in your relationship, how long you have known each person and how often and on what occasions you visited.
- 3
Give dates and places
Where a Yes answer asks for more, add the date and place in Items 12B and 12C, the periods lived together in Item 13B and details of other marriages in Items 15B and 16B.
- 4
Use Remarks or a separate sheet
For more space, the form says to use Item 17 or attach a separate sheet, showing the item number each answer applies to.
- 5
Sign, date and add phone numbers
Sign Item 18A in ink, date it and give daytime and evening phone numbers. A signature by X mark needs the two witnesses in Items 19 and 20.
- 6
Mail it
Page 2 gives the Pension Intake Center in Janesville, Wisconsin, as the mailing address.
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Where to send it
By mail
Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.
Privacy Act
The notice says the obligation to respond is voluntary, that the responses are considered confidential (38 U.S.C. 5701) and that the information is subject to verification through computer matching programs with other agencies.
Penalty
The form says the law provides severe penalties, including fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact knowing it to be false.
Edition
The current edition is dated MAY 2024. It carries OMB Control No. 2900-0115, which expires 05/31/2027, with a respondent burden of 20 minutes.
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Who uses VA Form 21P-4171?
The form describes the person giving the statement and the people it is about.
Official sources and the blank
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Questions about Form 21P-4171
Who fills out VA Form 21P-4171?
A person who knows the Veteran and the claimed spouse. The form asks for that person's name, address and relationship to each, and says to state None if not related.
What is the statement used for?
The certification says it will be considered in connection with an application for VA benefits based on a marital relationship between the Veteran and the person named in Item 3.
What if I do not know an answer?
The instructions say to write unknown.
Is filling out the form voluntary?
The Privacy Act notice on the form says the obligation to respond is voluntary and that the responses are considered confidential.
Where do I mail VA Form 21P-4171?
The form lists Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.
Can I sign with an X?
The form says a signature by mark is witnessed by two people who personally know the signer, and their signatures and addresses go in Items 19 and 20.