TN 28 (04-15)

RS 01702.442 Short-Form Application for Veterans Benefits, Department of Veterans Affairs (VA) Form 21-4182

A. When to complete the VA form 21-4182

An application filed for Title II survivor benefits by a survivor of a current or former member of the military service constitutes an application for VA benefits. Complete a VA form 21-4182 (Application for Dependency and Indemnity Compensation or Death Pension (Including Accrued Benefits and Death Compensation Where Applicable) From the Department of Veterans Affairs) for each survivor application when:

  • the number holder died while in the military service or had military service at any time; and

  • we have not received an SSA-24 (Application For Survivors Benefits (Payable Under Title II of the Social Security Act)) for the survivor from the VA, even if the claimant alleges having filed with the VA. (For more information on the SSA-24, see RS 01702.410.)

Mail or fax each completed VA form 21-4182 to the VA Regional Office (VARO) servicing the area where the claimant lives without waiting for requested proofs.

NOTE: The Honolulu VARO services the Northern Mariana Islands.

When a survivor does not apply for monthly Title II benefits or the special VA payment in non-insured cases, refer the survivor to the VA. Do not complete VA form 21-4182. For more information on the special VA payment, see RS 01702.540.

B. How to complete the VA form 21-4182

The majority of entries on VA form 21-4182 are self-explanatory. However, items that require special attention are:

1. Items 2A and 2B

Enter the name and relationship to the deceased veteran of the claimant named in the application for Title II benefits.

For example:

  • when the widow applies for benefits for herself and children, enter in Item 2A only the widow's name and check “widow” in Item 2B; or

  • when the claimant is filing only for child's benefits, enter in Item 2A the name of all children mentioned in the application, and check the “child” block in Item 2B.

NOTE: If all the children’s names do not fit in Item 2A, enter the names in the “Remarks” block.

2. Item 3A

Enter the VA file number for any prior applications filed by the veteran or survivors if provided by the claimant. Identify VA file numbers as follows:

  • a veteran’s VA file number begins with the letter “C;” and

  • a survivor’s VA file number begins with the letters “XC.”

NOTE: Do not complete Items 6A through 6D when the claimant furnishes a “C” or “XC” VA file number.

3. Items 6A through 6D

When the claimant furnishes the veteran's service number, enter it in Item 6B. Do not complete Items 6A, 6C, or 6D.

When the claimant cannot provide the veteran’s service number, or a “C” or “XC” file number, enter as much of the service history in 6A, 6C, and 6D as the claimant can provide. A complete and accurate service history will expedite the VA’s handling of the claim.

If the claimant is unsure of the veteran’s service dates, check the Veterans Benefits Administration Query (VBAQ), earnings record, and the Disability, Railroad, Alien and Military Service (DRAMS) file to help provide as much information as possible. Enter “unknown” for any service history information the claimant cannot provide.

For information on the VBAQ, see MSOM QUERIES 003.020. For information on DRAMS, see MSOM QUERIES 005.003.

4. Address of transmitting SSA office

Enter the address of the field office sending the VA form 21-4182 to the VA.

5. Application filing date

Enter the Title II survivor application filing date in the box on the application marked “DO NOT WRITE IN THIS SPACE.” For information on the application filing date, see GN 00204.007.