Statement of Marital Relationship
You have a common-law marriage that is valid under your state's law but you don't have a marriage certificate to submit to VA for dependency purposes.
Gather before you start
Attach with the form
Section I - Parties to the Marriage
Blocks 1-6Both parties' names, SSNs, DOBs, and addressPII
Both the veteran and spouse provide their identifying information.
(veteran and spouse legal names, SSNs, DOBs)
- Not first confirming your state recognizes common-law marriage - only about a dozen states do. VA only recognizes common-law marriages valid in the state where they were established.
Section II - Facts of the Marital Relationship
Blocks 7-12When, where, how the marriage was established and maintained
Describe: (1) When you began living together as a married couple, (2) The state where the informal marriage was established, (3) How you held yourselves out publicly as married (filed joint taxes, used same last name, introduced as husband/wife, listed as spouse on insurance/beneficiary forms, shared accounts).
e.g., We began cohabitating as a married couple in Phoenix AZ on 06/15/2015. We have filed joint federal tax returns since 2016, share bank accounts, I am listed as her spouse on her health insurance, and we introduce ourselves as husband and wife.
- Not providing enough detail about how you held yourselves out as married - VA needs factual evidence of the marital relationship.
- Submitting without the companion witness statement (21-4170) - witnesses corroborate your claim.
Section III - Signatures
Blocks 13-15Both parties' signaturesPII
Both the veteran and the spouse sign, certifying the information is accurate.
(both signatures)
- Only one party signing - VA requires both parties to certify their marital relationship.