Form 21-0538 Status of Dependents Questionnaire

STATUS OF DEPENDENTS QUESTIONNAIRE (CellPhoneNumber) (ChildsDateOfBirth) (ChildsDateOfBirth) (ChildsPlaceOfBirth) (ChildsPlaceOfBirth) (ChildsSocialSecurityNumber) (ChildsSocialSecurityNumber) (CITY STATE) (DATE SIGNED) (DateOfBirthOfSpouse) (DateOfMarriage) (DateOfTermination) (DateOfTermination3) (DateOfTermination4) (DaytimePhoneNumber) (death divorce age) (EveningPhoneNumber) (First Middle LastNameOfVeteran) (FullNameOfChild) (FullNameOfDependent) (FullNameOfDependent) (If "Yes " complete Items 3A 3E) YES2 ARE YOU MARRIED? (If child is not in the custody of person claiming (In Reply Refer To:) (MONTH DAY YEAR) (NameAndAddressOfPersonHavingCustodyOfChild) (NameAndAddressOfPersonHavingCustodyOfChild) (PlaceOfMarriage CityState) (ProvideReasonForTermination) (ProvideReasonForTermination) (Remarks) (SocialSecurityNumberOfSpouse) (text) (ToWhomWereYouMarried) 1 FIRST MIDDLE LAST NAME OF VETERAN 21 0538 3C TO WHOM WERE YOU MARRIED? (First name Middle Initial Last Name) 3D SOCIAL SECURITY NUMBER OF SPOUSE 3E DATE OF BIRTH OF SPOUSE (Month day year) 4A FULL NAME OF 4C PLACE OF 4D SOCIAL SECURITY 5A FULL NAME OF 5C DATE OF TERMINATION 6 REMARKS 7 TELEPHONE NUMBER(S) (Include Area Code) 8A SIGNATURE OF VETERAN OR GUARDIANSIGN HERE A DAYTIMEB EVENINGC CELL PHONE Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U S C 5101 (c) (1) The VA will not deny an individual APR 2013 benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1 1975 and still in effect Information that BIRTH Body of Letter regarding status of dependents (spouse child) Body of Letter regarding status of dependents (spouse child) Body of Letter regarding status of dependents (spouse child) Body of Letter regarding status of dependents (spouse child) Code of Federal Regulations 1 526 for routine uses (i e civil or criminal law enforcement congressional communications epidemiological ore research studies the collection of money collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs Department of Veterans Affairs Logo dependency allowance) EACH CHILD4B DATE OF EACH DEPENDENT5B PROVIDE REASON FOR TERMINATION HAVING CUSTODY OF THE CHILD I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief IN INK8B DATE SIGNED knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled NO3A DATE OF MARRIAGE (Month day year)3B PLACE OF MARRIAGE (City State) NOTE Please provide the following information for each child under age 18 over age 18 and under 23 and attending school or of any age if permanently disabled If NOTE: Furnish the following information for each terminated dependent NUMBER4E NAME AND ADDRESS OF PERSION OMB Approved No 2900 0500 owed to the United States litigation in which the United States is a party or has an interest the administration of VA programs and delivery of VA benefits verification of identity and Page 1 PENALTY The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5 Respondent Burden: 10 Minutes RESPONDENT BURDEN: We need this information to determine continued eligibility for an additional allowance for your spouse and/or child(ren) 38 U S C 1115 Title 38 United States Code allows us to ask for this information We estimate that you will need an average of 10 minutes to review the instructions find the information and complete this form status and personnel administration) as identified in the VA system of records 58VA21/22/28 Compensation Pension Education Vocational Rehabilitation and Employment Records the categories described above write "None" in Item 4A VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed Valid OMB control numbers can be located on the OMB Internet page at VA FORM VA FORM 21 0538 APR 2013Page 2 VA published in the Federal Register Your obligation to respond is required to obtain or retain benefits You must give us your and your dependents SSN account information www reginfo gov/public/do/PRAMain If desired you may call 1 800 827 1000 to get information on where to send comments or suggestions about this form you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits as well as to you have more than four children list the others in Item 6 "Remarks " giving the information requested in Items 4A thru 4E If you have no children in any of