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Federal forms, ICRs, and supporting documents

OMB control number

Statement of Marital Relationship (VA Form 21-4170)

OMB 2900-0114 · VA.

OMB 2900-0114

VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

The latest form for Statement of Marital Relationship (VA Form 21-4170) expires 2027-08-31 and can be found here.

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