21P-8924

Application of Surviving Spouse or Child for REPS Benefits (Restored Entitlement Program for Survivors)

Agency
VA
Revision
May 2024
Fillable fields
61
Pages
3
Official source
VA form page
Checked
October 20, 2026
Fill 21P-8924 online
Page 1 of form 21P-8924

VA Form 21P-8924: Application of Surviving Spouse or Child for REPS Benefits

VA Form 21P-8924 is the U.S. Department of Veterans Affairs Application of Surviving Spouse or Child for REPS Benefits, under the Restored Entitlement Program for Survivors. The form's information page says benefits are payable to certain survivors of members or former members of the Armed Forces who died while on active duty prior to August 13, 1981, or who died from a disability incurred in or aggravated by active duty prior to August 13, 1981.

The form is three pages. Sections I to V cover the Veteran, the claimant, employment and wages, remarks and the claimant's signature. Section VI is a certification signed by a VA official. Page 3 holds the eligibility information, the instructions and the mailing address. The form says it serves as an application for only one person. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 21P-8924: Application of Surviving Spouse or Child for REPS Benefits, as printed by VA

What's on VA Form 21P-8924

Section I: Veteran's information

The Veteran's name, Social Security number, VA file number, branch of service from Army to Space Force or other, and date of death.

Section II: Claimant's information

The claimant's name, date of birth, Social Security number, mailing address, phone, email, relationship to the Veteran as spouse or child, marital status and, if divorced or widowed, the dates of marriage and of its termination.

Section III: Employment and wages

Completed in full only by a surviving spouse whose youngest child in care has reached age 16 but is not yet 18. It asks employment status, total earnings for last calendar year and the maximum expected earnings for this and next calendar year.

Section IV: Remarks

Item 20 gives space for any remarks, and the instructions say to use it, or a separate sheet, when more space is needed.

Section V: Certification and signature

A certification that the statements are true and correct to the best of the claimant's knowledge, the signature in Item 21 and the date in Item 22.

Section VI: VA certification

The certification of service connection or death on active duty, with the VA official's signature and title, the VARO city and station number, and the date signed.

How to file VA Form 21P-8924

  1. 1

    Read page 3

    The instructions say to read the Privacy Act and Respondent Burden information on page 3 before completing the form.

  2. 2

    Complete Sections I and II

    Give the Veteran's details and the claimant's. If completed by hand, the form asks for ink, neat and legible printing and completely filled check boxes.

  3. 3

    Estimate wages if Section III applies

    The instructions say an estimate of wage information is required in Part III even when the exact amounts are not known.

  4. 4

    Add remarks or extra sheets

    Use Item 20 or attach a separate sheet labeled with the matching question numbers, with the Veteran's full name and VA file number on each sheet.

  5. 5

    Sign and date it

    The claimant, custodian or guardian signs Item 21, which the form marks required, and dates Item 22. Section VI carries the signature of a VA official.

  6. 6

    Mail it to VA

    The form says it should be returned to VA by mail at the VA Regional Office in St. Louis, Missouri.

Why fill Form 21P-8924 on indox

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Where to send it and getting help

Mailing address

VA Regional Office, 400 S. 18th St., St. Louis, MO 63103-2271.

Questions

The form points to https://www.va.gov/contact-us and the toll-free number 1-800-827-1000, with the Federal relay number 711 for TDD users.

Reporting changes

The form says it is your duty to report any changes in the information provided on the application, by calling the VA National Call Center at 1-800-827-1000.

Online

VA's form page offers the form as a downloadable PDF and lists no online version.

Edition

The May 2024 edition supersedes the June 2021 edition, which the form says will not be used. It carries OMB Approved No. 2900-0390, which expires 05/31/2027.

Related forms

Who uses VA Form 21P-8924?

  • Surviving spouses

    The form says a surviving spouse who was married to the Veteran at the time of death and is not currently married may be eligible when the youngest child in their care reaches age 16, and that these benefits end when the child reaches age 18.

  • Children of the Veteran

    The form describes an unmarried child of the Veteran between the ages of 18 and 21 attending a postsecondary school full time. It says a child age 18 still in high school is not eligible for REPS and may apply to the Social Security Administration for an extension of benefits.

  • Custodians or guardians

    Item 21 is the signature of the claimant, custodian or guardian, and the form marks it required.

  • VA officials

    Section VI holds the signature and title of a VA official, certifying that the deceased died on active duty, or from a service-connected disability incurred or aggravated, prior to August 13, 1981.

  • Service that does not qualify

    The form says service in the Public Health Service or National Oceanic and Atmospheric Administration does not qualify.

The form's information and instructions describe who applies and who signs.

Official sources and the blank

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Questions about Form 21P-8924

What is REPS?

The form names it the Restored Entitlement Program for Survivors. Its information page says benefits are payable to certain survivors of members or former members of the Armed Forces who died on active duty, or from a disability incurred in or aggravated by active duty, prior to August 13, 1981.

Who completes Section III?

The form says Section III is completed in full only by a surviving spouse whose youngest child in care has reached age 16 but is not yet 18.

Can one form cover more than one person?

No. The form says it is intended to serve as an application for only one person, and that more forms can be obtained at www.va.gov/vaforms.

What does the form say about a child who is 18 and still in high school?

The form says a child age 18 still in high school is not eligible for REPS, but may apply to the Social Security Administration for an extension of benefits.

Is my Social Security number required?

The Privacy Act notice says giving your SSN is mandatory and that applicants are required to provide it under Title 38 U.S.C. 5101(c)(1).

Where do I mail VA Form 21P-8924?

The form lists VA Regional Office, 400 S. 18th St., St. Louis, MO 63103-2271.