21P-524
Statement of Person Claiming to Have Stood in Relation of Parent
VA Form 21P-524 is the U.S. Department of Veterans Affairs Statement of Person Claiming to Have Stood in Relation of Parent. A claimant uses it to describe the relationship they had with a deceased Veteran: when and how they got custody or care of the Veteran, who supported the Veteran, and other facts that show the relationship. The form's burden notice says VA needs the information to determine eligibility for service-connected death benefits (38 U.S.C. 1315 and 5101).
The form is six pages. Part I is the claimant's own statement, and Parts II and III are statements from two disinterested persons who have personal knowledge of the relationship between the claimant and the Veteran. Each part ends with a certification and a signature in ink.
VA's page lists the form under 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.
The deceased Veteran's name and VA file number, then the claimant's name, mailing address, daytime and evening phone, relationship to the Veteran, Social Security number, date of birth and any marriage to a parent of the Veteran.
The Veteran's birth and death details, the Veteran's own father and mother, any marriage, the date the Veteran was placed in your custody or care, who placed the Veteran, and how you obtained custody or care.
The head of household and who gave the Veteran a place to live, schooling or training you provided, approximate amounts you spent on support, the Veteran's surviving brothers and sisters, and others who contributed to support or had custody or care.
Whether the Veteran contributed to your support, the Veteran's employment while in your custody or care, whether any record refers to you as a parent, and other facts that show the relationship.
The certification that the statements are true and correct, the date and the claimant's signature in ink, lines for two witnesses if signed by mark, and the penalty notice.
Each person gives their name, address, age and occupation, how long they knew the Veteran and the claimant, what they observed, facts showing whether or not the claimant acted as "parent", who supported the Veteran, and signs in ink.
The form says to answer all questions as fully as possible, enter "Unknown" if you do not know an answer and "None" or "N/A" if the answer is none.
Fill in Items 1 to 26. If more space is needed, the form says to attach a signed sheet of paper showing the item number the answer applies to.
Attach a copy of any written agreement made when the Veteran was placed in your custody or care, and letters, notes, records or other evidence that tend to show the relationship.
Enter the date in Item 27 and sign Item 28 in ink. A signature by mark needs two witnesses in Items 29 to 32.
Two disinterested persons with personal knowledge of the relationship each complete and sign one statement, Part II and Part III.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Neither the form nor VA's page prints a mailing address for VA Form 21P-524. Page 1 has a VA date stamp box marked "Do not write in this space".
The form says the letters, notes, records or other evidence you attach will be returned to you, if requested.
The burden notice says you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
The NOV 2023 edition supersedes VA Form 21-524, APR 2021, which will not be used. It carries OMB Control No. 2900-0059, which expires 11/30/2026, and an estimated burden of 2 hours.
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The instructions on page 1 say who completes each part.
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It is the statement of a person claiming to have stood in relation of parent to a deceased Veteran. The burden notice says VA needs the information to determine eligibility for service-connected death benefits.
The form says Parts II and III should each be completed by disinterested persons who have personal knowledge of the relationship which existed between the claimant and the Veteran.
The instructions say to enter "Unknown". If the answer is none, enter "None" or "N/A".
The form asks for a copy of any written agreement made when the Veteran was placed in your custody or care, plus letters, notes, records or other evidence that tend to show the relationship. It says the evidence will be returned to you, if requested.
The form says signatures made by mark are witnessed by two persons to whom the signer is personally known, and the witnesses' signatures and addresses are shown on the form.
The NOV 2023 edition says it supersedes VA Form 21-524, APR 2021, which will not be used.