U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) Edition VA Form 21-4170, AUG 2024 (OMB No. 2900-0114, expires 08/31/2027) 5 pages

VA Form 21-4170 — Statement of Marital Relationship

The statement VA uses to decide marital status when a couple lived together as married without a ceremonial marriage.

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VA Form 21-4170 · Statement of Marital Relationship
The official U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) form, edition VA Form 21-4170, AUG 2024 (OMB No. 2900-0114, expires 08/31/2027) — blank
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VA Form 21-4170 (2024) Statement of Marital Relationship — page 1 of 5
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Fill this form online Blank PDF from U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA)

What is VA Form 21-4170?

VA Form 21-4170 gives VA the information it needs to determine your marital status, typically for a common-law marriage. The form's instructions say it is completed by the Veteran (if living) and the person claiming to be the spouse or surviving spouse, and asks you to submit documents showing that you held yourselves out as married or are generally accepted as married where you live or lived: for example lease agreements, joint bank statements, utility bills, tax returns, insurance forms and employment records.

It covers the Veteran's and the claimed spouse's identification and mailing address; when and where you began living as marital partners, the names you used before, whether you used the Veteran's last name, what you agreed your relationship would be and whether you lived together continuously; periods of separation and every place you lived together; children you had together; all earlier marriages of each of you; remarks; and both signatures.

FileIt pre-fills the spouse's name and date of birth from the person's vault record, shows the follow-up questions only when they apply, prints every answer letter by letter in the form's boxes on VA's own PDF (AUG 2024 edition), and checks that nothing will be cut off. Both of you can sign by hand or with FileIt's eSignature. FileIt never submits anything to VA.

Who fills it
The Veteran (if living) and the claimed spouse or surviving spouse. Items 11D to 13 are completed by the spouse.
Signatures
18A, the Veteran, and 19A, the claimed spouse or surviving spouse. A signature by "X" mark needs two witnesses (Section VIII).
Pages
5: four pages of questions and signatures, and a page of mailing addresses.
Mail to
Page 5 lists VA's intake addresses: compensation claims to the Evidence Intake Center (PO Box 4444, Janesville, WI 53547-4444), pension and survivors claims to the Pension Intake Center (PO Box 5365, Janesville, WI 53547-5365).
Edition
VA Form 21-4170, AUG 2024 (OMB No. 2900-0114, expires 08/31/2027)

Who needs to fill out VA Form 21-4170?

  • A Veteran and partner whose marriage was not a ceremonial one, when VA needs to decide whether the partner counts as a spouse.
  • A surviving partner claiming benefits as a Veteran's surviving spouse after a common-law marriage.

When to use VA Form 21-4170

  • When VA asks you to establish a marital relationship that wasn't created by a ceremony.
  • When adding a common-law spouse as a dependent, or claiming survivors benefits as a common-law surviving spouse.

What you need before you start

  • The Veteran's Social Security number, VA file number and service number (if any), and both dates of birth.
  • The date and address where you began living together, and every period and address you lived together since.
  • Dates and reasons for any separations.
  • Names and birthplaces of children you had together, and certified copies of their birth records.
  • Details of every earlier marriage of each of you, with copies of divorce decrees.
  • Documents showing you held yourselves out as married, such as leases, joint bank statements, tax returns or insurance forms.

What’s on VA Form 21-4170

The 2024 edition has 5 pages. FileIt asks for it in 8 parts, and it is signed by Claimed spouse or surviving spouse and Veteran (if living):

  1. Section I: Veteran's identification informationClaimed spouse or surviving spouse
  2. Section II: Spouse or surviving spouse's identification informationClaimed spouse or surviving spouse
  3. Section III: Information about the marital relationship claimedClaimed spouse or surviving spouse
  4. Section IV: Information about your childrenClaimed spouse or surviving spouse
  5. Section V: Information about your marital historyClaimed spouse or surviving spouse
  6. Section VI: RemarksClaimed spouse or surviving spouse
  7. Section VII: Signature of the claimed spouse or surviving spouseClaimed spouse or surviving spouse
  8. Veteran's signature (if the veteran is living)Veteran (if living)

How to fill out VA Form 21-4170, step by step

1 Sections I and II: Identification

The Veteran's name, SSN, VA file number, date of birth, service number and phone; then the spouse's name, SSN and date of birth, and the mailing address.

2 Section III: The relationship

Item 11: when and where you began living as marital partners, names used before, whether you used the Veteran's last name, what you agreed your relationship would be, and whether you lived together continuously. Item 12 lists periods of separation (only if not continuous); item 13 every period and place you lived together.

3 Section IV: Children

Whether you had children together, and each child's full name and place of birth.

4 Section V: Marital history

Items 15 and 16: whether the Veteran, or the spouse, ever lived with another person as a marital partner, and the date, place and partner of each marriage and how and when it ended.

5 Sections VI to VIII: Remarks and signatures

Use Remarks for anything that doesn't fit, with the item number. Then both of you certify the statements are true and sign. If either signs by "X" mark, two witnesses who know you sign and give their addresses.

Common mistakes to avoid

  • Leaving questions blank instead of writing "unknown", which the form asks you to do when you don't know an answer.
  • Listing only some earlier marriages: the form asks for all marriages of both of you.
  • Forgetting the second signature: the form marks both 18A and 19A as required.
  • Sending original documents: the form says originals won't be returned and encourages certified copies.

After you fill it out

Both sign and date Section VII, by hand or with FileIt's eSignature.

Attach the documents showing your relationship, the children's birth records and any divorce decrees.

Send it to the VA address on page 5 for your type of claim, or upload it through VA's online tools the page points to.

Keep a copy. FileIt files the finished PDF in the person's vault folder.

Fill out VA Form 21-4170 online with FileIt

  1. Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
  2. Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 98 fields in all. Your answers save as you go.
  3. Check the live preview. Watch your answers land on the real U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) form, and let FileIt do any worksheet arithmetic.
  4. Generate the official PDF. FileIt prints your answers into the agency’s own PDF and files it in that person’s folder in your vault. Sign it, or send it for e-signature.

FileIt fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.

Start VA Form 21-4170 now — it’s free

VA Form 21-4170: frequently asked questions

What is VA Form 21-4170 used for?

To give VA information to determine your marital status, for example when a Veteran and partner lived together as married without a ceremonial marriage.

Who signs it?

The Veteran, if living (18A), and the claimed spouse or surviving spouse (19A). Both are marked required.

What if one of us signs with an X?

Section VIII says a signature by mark must be witnessed by two people who personally know the signer, and their signatures and addresses go on the form.

What documents should we send?

The form suggests documents that show you held yourselves out as married, such as leases, joint bank statements, utility bills, tax returns, insurance forms and employment records, and says certified copies are encouraged because originals won't be returned.

Does VA recognize every common-law marriage?

This form only collects the facts and your supporting documents; VA decides your marital status from them. Answer every question, writing "unknown" where you don't know.

Official sources

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-25.

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