Complete the VA Form 21-4180 following instructions in RS 01702.580E in this section. Process the SSA-24 following instructions in RS 01702.424.

If we already processed a claim for all survivors listed on the VA Form 21-4180, complete the 21-4180 and return it to the VA.

If there is no record of a claim for any of the survivors listed on the VA Form 21-4180, send the form to the FO servicing the principal survivor's address, requesting claim development.

Although the VA completes Part I of the VA Form 21-4180, enter the veteran’s SSN in Item 4 if missing or incorrect. Contact the survivor for the veteran’s SSN, if necessary.

FOs and PCs complete Part II of the VA Form 21-4180 for each of the claimants listed in Item 7.A. When there is more than one claimant listed in Item 7.A and the status of the claimants is different, attach a brief statement to the form explaining the status of each claimant. For example, “Person A - Insured status established and award attached. Person B - Certification may be made at age 60. Person C - Not eligible at this time.”

Complete Part II as follows:

1. a. 

   Item 10A – When certifying an award for the special VA payment, check the appropriate block. (For instructions on certifying an award, see RS 01702.553.) If not making an award for the special VA payment, leave 10A blank.

2. b. 

   Item 10B – Enter date as appropriate.

3. c. 

   Item 11A – Check block 11A when the veteran died insured for Social Security purposes and the survivor(s) is either currently entitled or may be potentially entitled to benefits at some future date (a widow under age 60 without children, or a dependent parent under entitlement age).

4. d. 

   Item 11B – Check block 11B when the veteran is uninsured and the widow(er) is potentially eligible for the special VA payment at age 60 or later. Check this block even if the widow(er) is now entitled to Title II benefits on another earnings record. For the future development of a claim for the VA payment when this block is checked, see RS 01702.546.

5. e. 

   Item 11C – Check block 11C when the veteran is uninsured and a survivor(s) listed on the VA Form 21-4180 would be ineligible to receive benefits even if the veteran had been insured. If the ineligible survivor is the widow(er), check this block only if you know that the widow(er) will not be eligible to receive the VA payment at age 60. This block is also checked if the Railroad Retirement Board (RRB) has jurisdiction.

6. f. 

   Items 12 to 14 – Sign and date the form. Enter your office’s mailing address.

Upon completing the VA Form 21-4180:

• •

  fax the completed form into the Non Disability Repository for Evidentiary Documents (NDRED) using the Evidence Portal (EP); and

• •

  return the VA Form 21-4180 to the VA regional office address shown in Item 2 of the form or to the RRB, as appropriate.