VA Form 21-4170
Statement of Marital Relationship (Witness)
Who fills it
representative
Journey phase
Keeping Your Award Current
Estimated time
15-20 minutes for the witness.
When to file
With VA Form 21-3288.
A witness with personal knowledge of the couple's informal marriage provides their independent corroboration.
Gather before you start
—Witness name, address, relationship to the couple
—How the witness knows the couple
—Specific facts the witness has observed about the marital relationship
Section I - Witness Identification
Blocks 1-4Witness name, address, phone, relationship to couplePII
The witness providing corroboration. Strong witnesses include: long-time neighbors, family members, coworkers, or anyone who has observed the couple over time.
Example
e.g., Thomas Brown, neighbor, 458 Oak Ave, Phoenix AZ; has known couple since 2015.
Common mistakes
- Witnesses with no direct knowledge of the relationship providing a statement - VA gives much more weight to witnesses who can describe specific facts they observed.
Section II - Witness Statement
Blocks 5-8What the witness personally observed about the marital relationship
The witness describes specific facts they have personally observed: how long they have known the couple, that the couple lives together as a married couple, that they introduce themselves as husband and wife, any specific observations confirming the marital relationship.
Example
e.g., I have known John Smith and Jane Smith as neighbors since June 2015. They live together at the same address, introduce themselves to me as husband and wife, and I have observed them attending family functions together as a married couple over the past 10 years.
Common mistakes
- Vague statements ("they seem married") without specific factual observations.
- Witnesses simply stating "they told me they were married" rather than what they personally observed.
Authority
38 CFR 3.50 - Defines spouse for VA compensation/pension purposes; covers ceremonial, common-law, and same-sex marriages.
Section III - Witness Certification
Blocks 9-10Witness signature and date
The witness signs and dates under penalty of perjury.
Example
(witness signature/date)
Common mistakes
- Veteran signing instead of the witness - the witness must sign this form.
Statutory & regulatory authority
38 CFR 3.50 - Defines spouse for VA compensation/pension purposes; covers ceremonial, common-law, and same-sex marriages.