Statement of Person Claiming to Have Stood in Relation of Parent
You raised the veteran as a parent but are not their biological or adoptive parent. You stood in loco parentis for at least one year before the veteran turned 21.
Gather before you start
Attach with the form
Section I - Claimant Identification
Blocks 1-3Your name, address, relationship typePII
Your name and how you relate to the veteran. Examples: foster parent, stepparent (not legally adoptive), grandparent who raised the veteran, uncle/aunt who raised the veteran.
e.g., Mary Jones, foster parent; raised veteran from ages 3-19
- Stating "stepparent" without clarifying the stepparent legally married the biological parent - marriage to the biological parent is the key fact.
Section II - Nature and Duration of Parental Relationship
Blocks 4-10When, how, and for how long you stood in loco parentis
Describe specifically: (1) When you took in the veteran and at what age, (2) How long you acted as parent (must be at least 1 year before the veteran turned 21), (3) What parental functions you performed (paid for food, clothing, medical care, schooling, provided housing), (4) Whether the veteran considered you a parent. The more specific the narrative, the stronger the claim.
e.g., I took John Smith into my home in June 1975 when he was age 7, following the death of his mother (my sister). He lived with me continuously until he enlisted in the Army in 1986 at age 18. I provided his food, clothing, medical care, and paid for his schooling. He called me "Mom" and I claimed him as a dependent on my tax returns from 1975-1986.
- Vague descriptions ("I raised him") without specific dates and parental functions - VA needs to verify the in loco parentis relationship through concrete evidence.
- Not addressing the duration - must clearly show at least 1 year of parental care before veteran reached age 21.
Section III - Witnesses
Blocks 11-14Names and contact information of witnesses who observed the relationshipRepeatable
Provide names, addresses, and phone numbers of people who can attest to your in loco parentis relationship with the veteran: relatives, neighbors, teachers, coaches, clergy, or anyone who observed you functioning as the veteran's parent.
e.g., Rev. Thomas Brown, 789 Church St, Tucson AZ 85701; neighbor who observed from 1975-1986.
- Listing witnesses without contact information - VA cannot verify without being able to reach them.
- Only listing deceased witnesses - live witnesses who can be interviewed are far more useful.
Section IV - Signature
Blocks 15-16Claimant signature and datePII
Sign and date under penalty of perjury.
(your signature/date)
- Not attaching corroborating evidence (tax returns, school records) - the statement alone is often insufficient.