How to Fill Out VA Form 21-4170: Statement of Marital Relationship

VA Form 21-4170, the Statement of Marital Relationship, is how you and your spouse give the VA sworn details about a common-law marriage when no marriage certificate exists. To fill out VA Form 21-4170, both parties complete separate copies covering when and where you began living as married partners, every address you shared, any prior marriages, and children born of the relationship, then sign under penalty of perjury and submit the form alongside VA Form 21-686c, two witness statements on VA Form 21P-4171, and supporting documents.

When You Actually Need This Form

Most Veterans adding a spouse never touch Form 21-4170. A certified copy of a civil or religious marriage certificate satisfies the VA’s proof-of-marriage requirements under 38 C.F.R. § 3.205.¹ The 21-4170 is the substitute when a marriage lacks standard documentation, almost always because it is a common-law marriage recognized by the state where the couple lived.²

A common-law claim is not a single form. The VA Form 21-686c instructions require four pieces on top of the standard dependency application:³

One 21-4170 completed and signed by the Veteran
A separate 21-4170 completed and signed by the spouse or surviving spouse
Two VA Forms 21P-4171, each from a different person who personally observed the relationship
Certified birth certificates for any children born of the common-law marriage

All four go in together. If any piece is missing, the VA sends a development letter and the claim stalls for weeks or months while you catch up.

Download the current version, revised August 2024, from VA.gov before you start.⁴ Print answers clearly. If you truly do not know an answer, write “unknown” rather than leave a field blank.⁵

Section I — Veteran’s Identification

Enter the Veteran’s full legal name, Social Security number, VA file number if one has been assigned, date of birth, service number, and telephone number. The VA file number ties this form to the existing benefits record. If no claim has ever been filed and no file number exists, leave that field blank.

Section II — Spouse or Surviving Spouse’s Identification

Provide the spouse’s or surviving spouse’s full name, Social Security number, date of birth, and current mailing address. The VA uses that address for follow-up correspondence, so use one you actually check.

Section III — The Marital Relationship

This is the section adjudicators read most carefully. It should contain:

The exact or approximate date you began living together as a married couple
Both parties’ full names before the relationship began
The full address where cohabitation started
Whether the spouse used the Veteran’s last name always, sometimes, or never
What both parties agreed the relationship would be when you began living together; a direct statement such as “we agreed to be married” carries more weight than vague language
Whether you lived together continuously until the present date or until the Veteran’s death
Every period of separation with start and end dates and the reason; deployments, work assignments, and family emergencies do not hurt a claim, but unexplained gaps raise questions
Every address where you lived together, with approximate dates

The addresses you list here need to line up with what your witnesses put on their 21P-4171 forms. Contradictions between the two are one of the fastest ways to trigger a development letter or a denial.

Behind the form is 38 C.F.R. § 3.205(a)(6), which requires affidavits from both parties covering the agreement between them when they began living together, the period and places of cohabitation, and whether children resulted, backed by statements from at least two other people who personally observed the couple living as spouses.¹ Section III is the VA’s structured way of collecting that from you.

Section IV — Children

List the full name and place of birth for each child born to both of you. Children born during the relationship are strong evidence that a marital relationship existed. Attach a certified birth certificate for each child listed.⁵

Section V — Prior Marriage History

Both parties must disclose every prior marriage, formal or common-law: the name of the former spouse, dates and places of marriage and dissolution, and how each marriage ended (divorce, annulment, or death). Attach copies of divorce decrees.⁵ An unresolved prior marriage is the single most common reason a common-law claim is denied, because it creates a legal impediment to the current marriage.

If a surviving spouse entered the marriage without knowing about a legal impediment, the VA may still treat the marriage as valid under 38 U.S.C. § 103, provided the surviving spouse lived with the Veteran for at least one year immediately before death or the couple had a child together.⁶ Note that situation in the Remarks section and include a signed statement that you had no knowledge of the impediment.

Section VI — Remarks

Use this space for anything that does not fit the other sections. If you ran out of room listing addresses or prior marriages, continue here and reference the item number. This is also where to explain unusual circumstances, such as why documentation from early in the relationship is unavailable or why a name change was informal.

Section VII — Signatures

Both the Veteran and the claimed spouse or surviving spouse must sign and date the form. If only the surviving spouse is alive, only their signature is required. A signature by “X” mark, for someone unable to write, must be witnessed by two people who know the signer personally.⁵

Supporting Documents to Attach

The form instructions ask for any records showing the two of you held yourselves out as married. The VA specifically suggests:⁵

Lease agreements or mortgage documents listing both names
Joint bank account statements
Utility bills in both names or at a shared address
Joint tax returns filed as married
Insurance policies naming one partner as the spouse
Employment records listing a spouse or emergency contact

Joint tax returns filed as “married filing jointly” are particularly persuasive because they carry penalties for misrepresentation. If your relationship began decades ago and most of these papers no longer exist, lean harder on detailed witness statements through Form 21P-4171 and use the Remarks section to explain why documentation is limited.

Where to Send the Package

The fastest route is electronic upload through the QuickSubmit tool at AccessVA, which replaced the older Direct Upload tool.⁷ Sign in with your VA credentials to reach it.⁸

If you mail the package, match the address to your claim type:⁵

Compensation claims: Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444
Pension and survivors benefit claims: Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365

Surviving spouses filing for Dependency and Indemnity Compensation should use the pension and survivors address. Sending forms to the wrong PO Box will not kill the claim, but it can add time while the VA routes the package internally.

After You Submit

The VA confirms receipt and begins review. You can track status through your VA.gov account.⁹ During review, the VA may send a development letter asking for more evidence, most often because the witness statements on the 21P-4171 forms disagree with the addresses or dates on your 21-4170, or because a prior marriage’s dissolution is not documented. Respond promptly and completely. The VA compares details across all four submitted forms, so consistency matters more than polish.

If the claim is denied, you have three ways to challenge the decision:¹⁰

Supplemental Claim on VA Form 20-0995, for cases where you have new evidence the VA has not seen. This is the usual path for common-law denials, because the fix is typically better evidence.
Higher-Level Review on VA Form 20-0996, in which a senior reviewer re-examines the existing record. Choose this if the original reviewer misapplied the regulation or overlooked evidence already in the file.
Board Appeal on VA Form 10182, which takes the case to the Board of Veterans’ Appeals and lets you request a hearing.

A Veterans Service Organization representative or accredited claims agent can help you pick the right route. The VA keeps a searchable directory of accredited representatives at va.gov/ogc/apps/accreditation.

1
eCFR. 38 CFR 3.205 – Proof of Marriage
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Veterans Affairs. Important Information on Marriage
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Department of Veterans Affairs. VA Form 21-686c – Application Request to Add and/or Remove Dependents
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Veterans Affairs. VA Form 21-4170
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Department of Veterans Affairs. VA Form 21-4170 – Statement of Marital Relationship
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Office of the Law Revision Counsel. 38 USC 103 – Special Provisions Relating to Marriages
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VA News. QuickSubmit Is the New Evidence Intake Tool for VA Claims
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Veterans Affairs. Upload Evidence to Support Your Disability Claim
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Veterans Affairs. The VA Claim Process After You File Your Claim
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Department of Veterans Affairs. Decision Review Request: Supplemental Claim