Certificate Showing Residence and Heirs of Deceased Beneficiary
The designated VA life insurance beneficiary has died before or after the insured, and there is no alternate beneficiary. Heirs need to be established for payment.
Gather before you start
Attach with the form
Section I - Deceased Insured/Beneficiary Identification
Blocks 1-4Insured name, policy number, date of death; beneficiary name and date of deathPII
Identify the VA insurance policy holder and any designated beneficiary who has also died. The dates of death determine the order of legal succession.
(insured and beneficiary identifying information)
- Not having death certificates for all relevant parties - VA cannot determine succession without them.
Section II - Legal Heirs
Blocks 5-15All surviving heirs with full identifying informationPII
List all surviving legal heirs in order of succession under applicable state law. Typical order: (1) Spouse, (2) Children equally, (3) Parents, (4) Siblings. Include each heir's full legal name, SSN, DOB, address, and relationship.
e.g., Jane Smith (surviving spouse), SSN: 123-45-6789, DOB: 05/10/1952; Emily Smith (daughter), SSN: 234-56-7890, DOB: 06/15/1985.
- Not including all heirs - VA distributes to all heirs in the same priority class.
- Not knowing probate may be required if the estate exceeds state thresholds - consult an estate attorney.
Section III - Certification
Blocks 16-17Claimant/estate representative certificationPII
Sign and date under penalty of perjury certifying heir relationships are accurate.
(signature/date)
- Attempting to claim without legal standing - if disputed, VA may require probate court determination.