Form VA Form 21-8924 VA Form 21-8924 Application of Surviving Spouse or Child for REPS Benefi

OMB Approved No. 2900-0390
Respondent Burden: 20 minutes

APPLICATION OF SURVIVING SPOUSE OR CHILD FOR REPS BENEFITS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)

PRIVACY ACT INFORMATION: 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 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or
research studies, the collection of money 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 status, and personnel administration) as identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is
required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101(c)
(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect
prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The
responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other
agencies.
RESPONDENT BURDEN: We need this information to determine eligibility for REPS benefits (38 U.S.C. 5101 (a)). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this
number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

IMPORTANT INFORMATION
WHO IS ELIGIBLE: 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. Service in the Public Health Service or National Oceanic and Atmospheric Administration does not qualify.
SURVIVING SPOUSE: If you were married to the veteran at the time of his or her death and are not currently married, you may be
eligible for REPS benefits for yourself when the youngest child in your care reaches age 16. These benefits will terminate when the
child reaches age 18, whether or not the child is still in high school.
CHILD: If you are an unmarried child of the veteran between the ages of 18 and 22 and are attending a postsecondary school full
time, you may be eligible for REPS. In the United States, "postsecondary school" refers to school above the level of high school. If
you are age 18 and still in high school, you are not eligible for REPS. However, you may apply to the Social Security Administration
for an extension of benefits.
INSTRUCTIONS
If you are applying as a surviving spouse whose youngest child in care is age 16 or 17, write your own name in Item 6 below. You
should leave Part II blank. All other questions on the form pertain to you and not to your child. If you are the veteran's child, age 18
to 22 and attending college or other postsecondary school full time, you should enter your name in Item 6. All the questions on this
form pertain to you. If you are signing as parent or guardian on behalf of a child who is about to turn 18, be sure to enter the child's
name in Item 6 and answer all questions on the form with information about the child. NOTE: This form is intended to serve as an
application for only one person. Additional forms can be obtained from your nearest VA regional office.
NOTE: Action on your claim may be delayed if you do not provide all of the information requested. You are required to estimate
wage information in Part III, even if you do not know exactly what your wages will be. If you need additional space, use Item 22,
"REMARKS", or attach a separate sheet and label your answers to correspond to the question numbers on the form. Please include
the veteran's full name and VA file number on each sheet. Please type or print in ink.
SEND THE COMPLETED FORM TO THE VA REGIONAL OFFICE, 400 S. 18TH STREET, ST. LOUIS, MO 63103-2271.
PART I - TO BE COMPLETED BY CLAIMANT

1. FIRST-MIDDLE-LAST NAME OF DECEASED

2. SOCIAL SECURITY NO. OF DECEASED

XC-

4. BRANCH OF SERVICE OF DECEASED

ARMY

NAVY

5. DATE OF VETERAN'S DEATH

AIR FORCE

MARINES

COAST GUARD

7. DATE OF BIRTH (Month,day,year)

6. FIRST - MIDDLE - LAST NAME OF CLAIMANT (SEE INSTRUCTIONS)
9. RELATIONSHIP TO DECEASED

NO

8. SOCIAL SECURITY NUMBER

10. ADDRESS OF CLAIMANT (Number and street or rural route, city or P.O., State and ZIP Code)

11A. HAVE YOU MARRIED SINCE THE VETERAN'S DEATH?
YES

3. VA FILE NUMBER

11B. DATE YOU MARRIED

11C. DATE YOUR MARRIAGE TERMINATED

(If "Yes," complete Items 11B and 11C)
PART II - TO BE COMPLETED ONLY IF CLAIMANT IS CHILD ENROLLED IN POSTSECONDARY SCHOOL

NOTE: Complete information for periods of attendance after eighteenth birthday.
12A. ARE YOU A FULL-TIME STUDENT IN A COURSE BEYOND THE HIGH SCHOOL LEVEL?
YES

12B. DATE OF HIGH SCHOOL COMPLETION

NO

13. CURRENT SCHOOL YEAR
A. NAME AND ADDRESS OF SCHOOL

DATES OF ATTENDANCE
B. BEGINNING DATE (Mo.,day,year) C. ENDING DATE (Mo.,day,year)

D. TYPE OF SCHOOL
COLLEGE - UNDERGRADUATE LEVEL
TECHNICAL, TRADE OR VOCATIONAL
VA FORM
JUN 2011

21-8924

COLLEGE - GRADUATE LEVEL
OTHER (Specify)

E. FOR COLLEGE LEVEL
PROGRAMS INDICATE
ATTENDANCE BASIS
SEMESTER HOURS

EXISTING STOCK OF VA FORM 21-8924, FEB 2005,
WILL BE USED.

QUARTER HOURS

F. NUMBER OF HOURS PER
WEEK SCHEDULED TO
ATTEND

14. LAST SCHOOL YEAR
A. NAME AND ADDRESS OF SCHOOL

DATES OF ATTENDANCE
B. BEGINNING DATE (Mo.,day,year) C. ENDING DATE (Mo.,day,year)

D. TYPE OF SCHOOL
COLLEGE - UNDERGRADUATE LEVEL
TECHNICAL, TRADE OR VOCATIONAL

E. FOR COLLEGE LEVEL
PROGRAMS INDICATE
ATTENDANCE BASIS
SEMESTER HOURS

COLLEGE - GRADUATE LEVEL
OTHER (Specify)

F. NUMBER OF HOURS PER
WEEK ATTENDED

QUARTER HOURS

15. DO YOU INTEND TO CONTINUE OR RETURN TO SCHOOL IN FULL-TIME ATTENDANCE AFTER THE DATE ENTERED IN ITEM 13C?
YES

NO

(If "Yes," complete Items 16A thru 16F)
16. FUTURE SCHOOL YEAR

A. NAME AND ADDRESS OF SCHOOL

DATES OF ATTENDANCE
B. BEGINNING DATE (Mo.,day,year) C. ENDING DATE(Mo.,day,year)

D. TYPE OF SCHOOL
COLLEGE - UNDERGRADUATE LEVEL
TECHNICAL, TRADE OR VOCATIONAL

F. NUMBER OF HOURS PER
WEEK SCHEDULED TO
ATTEND

E. FOR COLLEGE LEVEL
PROGRAMS INDICATE
ATTENDANCE BASIS
SEMESTER HOURS

COLLEGE - GRADUATE LEVEL
OTHER (Specify)

QUARTER HOURS

17. WILL YOU BE PAID OR HAVE YOU BEEN PAID BY YOUR EMPLOYER TO ATTEND SCHOOL?
YES

NO

(If "Yes," give your employer's name and address)
PART III - EMPLOYMENT AND WAGE INFORMATION

(To be completed in full by each applicant. "N/A" or "Unknown" are not acceptable)
18. ARE YOU NOW EMPLOYED?

(If "Yes," enter your
employer's name and
NO address in Item 22)

19. DO YOU EXPECT TO BE EMPLOYED NEXT YEAR?

NO
YES
YES
20B. MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR THIS
CALENDAR YEAR? (You must make an estimate)

$

(Year)

20D. ARE YOU SELF-EMPLOYED?

20A. TOTAL EARNINGS FROM EMPLOYMENT FOR
LAST CALENDAR YEAR

$

(Year)

20C. MAXIMUM EXPECTED EARNINGS FROM EMPLOYMENT FOR NEXT
CALENDAR YEAR? (You must make an estimate)

$

(Year)

20E. HOW MANY HOURS PER MONTH DO YOU WORK IN SELF-EMPLOYMENT?

YES
NO (If "Yes," complete Item 20E)
21. NAME(S), ADDRESS(ES) AND RELATIONSHIP TO DECEASED OF ANY OTHER SURVIVOR(S) (For relationship use: Surviving Spouse, Child under 18 years of

age, or full-time Postsecondary School Student)

22. REMARKS

IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGES IN STATUS. You must notify VA immediately of any
change in school enrollment, marital, or work status as benefits may be affected. To report any changes, please contact the St. Louis,
MO VA Regional office. You may contact us by telephone at (314) 552-9803, by fax at (314) 552-9817, or by mail at the address
shown in the instructions.
I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
23A. SIGNATURE OF CLAIMANT, CUSTODIAN, OR GUARDIAN

23B. DAYTIME PHONE NUMBER (Include Area Code) 23C. DATE SIGNED

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, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
PART IV - TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS
24. POSTSECONDARY SCHOOL APPROVAL DATA
A. NAME(S) OF SCHOOL(S)

B. ARE REQUIREMENTS
OF M21-1, PART IV,
PAR. 14.06 MET?

C. APPROVAL DATE(S)

(January 1, 1983 or later)

D. FULL-TIME
ATTENDANCE

(Hours)

CURRENT
PREVIOUS
I HEREBY CERTIFY THAT the deceased died on active duty prior to August 13, 1981, or died from a service-connected disability incurred or aggravated prior to August 13, 1981.

CERTIFICATION OF SERVICE-CONNECTION OR DEATH ON ACTIVE DUTY

25A. SIGNATURE AND TITLE OF VA OFFICIAL

VA FORM 21-8924, JUN 2011

25B. VARO (City) AND STATION NUMBER

25C. DATE SIGNED