TN 31 (02-16)

A. Purpose of VA Form 21-4180

The Veteran’s Administration (VA) uses the VA Form 21-4180 (Request for Certification by Social Security Administration) to obtain information from us on whether a veteran’s survivor or survivors may be eligible for the special VA payment under 38 U.S.C. 1312(a). For information on the special VA payment, see RS 01702.540.

B. VA completion of VA Form 21-4180

VA completes Part I of VA Form 21-4180 and then faxes or mails the completed form to the:

• payment center (PC) servicing the veteran's Social Security Number (SSN) entered on the VA Form 21-4180; or

• field office (FO) nearest the VA office if the VA does not know the veteran’s SSN. The receiving FO immediately forwards the VA Form 21-4180 to the FO servicing the principal survivor's address.

When a veteran’s survivor files a claim for VA benefits, he or she also completes an SSA-24 (Application for Survivors Benefits (Payable under Title II of the Social Security Act)). Before the VA sends us a completed SSA-24, it determines whether the veteran's death was service-connected. If the veteran’s death was service-connected, the VA sends us both the SSA-24 and a VA Form 21-4180. The VA also may send us the VA Form 21-4180 without a corresponding SSA-24.

C. FO processing of VA Form 21-4180

When receiving both an SSA-24 and a VA Form 21-4180, process the SSA-24 following instructions in RS 01702.424. When receiving only the VA Form 21-4180, treat it as a lead for Title II benefits for the survivor(s) listed on the 21-4180.

After determining the survivor’s eligibility for Title II benefits, complete the VA Form 21-4180 as instructed in RS 01702.580E in this section, and return it to the VA. If you cannot obtain the information needed to complete the VA Form 21-4180 because the survivor(s):

• does not file a Title II claim;

• does not respond to your letters; or

• refuses to cooperate in developing a claim or in furnishing information for the 21-4180, then

return the VA Form 21-4180 to the VA with the appropriate explanation (Survivor did not file a Title II claim).

If we do not return the VA Form 21-4180 to the VA within 90 days, the VA will send a second request.

D. PC processing of VA Form 21-4180

1. VA Form 21-4180 received with an SSA-24

Complete the VA Form 21-4180 following instructions in RS 01702.580E in this section. Process the SSA-24 following instructions in RS 01702.424.

2. VA Form 21-4180 received without an SSA-24

If we already processed a claim for all survivors listed on the VA Form 21-4180, complete the 21-4180 and return it to the VA.

If there is no record of a claim for any of the survivors listed on the VA Form 21-4180, send the form to the FO servicing the principal survivor's address, requesting claim development.

E. Completing the VA Form 21-4180

1. Part I

Although the VA completes Part I of the VA Form 21-4180, enter the veteran’s SSN in Item 4 if missing or incorrect. Contact the survivor for the veteran’s SSN, if necessary.

2. Part II

FOs and PCs complete Part II of the VA Form 21-4180 for each of the claimants listed in Item 7.A. When there is more than one claimant listed in Item 7.A and the status of the claimants is different, attach a brief statement to the form explaining the status of each claimant. For example, “Person A - Insured status established and award attached. Person B - Certification may be made at age 60. Person C - Not eligible at this time.”

Complete Part II as follows:

1. Item 10A – When certifying an award for the special VA payment, check the appropriate block. (For instructions on certifying an award, see RS 01702.553.) If not making an award for the special VA payment, leave 10A blank.

2. Item 10B – Enter date as appropriate.

3. Item 11A – Check block 11A when the veteran died insured for Social Security purposes and the survivor(s) is either currently entitled or may be potentially entitled to benefits at some future date (a widow under age 60 without children, or a dependent parent under entitlement age).

4. Item 11B – Check block 11B when the veteran is uninsured and the widow(er) is potentially eligible for the special VA payment at age 60 or later. Check this block even if the widow(er) is now entitled to Title II benefits on another earnings record. For the future development of a claim for the VA payment when this block is checked, see RS 01702.546.

5. Item 11C – Check block 11C when the veteran is uninsured and a survivor(s) listed on the VA Form 21-4180 would be ineligible to receive benefits even if the veteran had been insured. If the ineligible survivor is the widow(er), check this block only if you know that the widow(er) will not be eligible to receive the VA payment at age 60. This block is also checked if the Railroad Retirement Board (RRB) has jurisdiction.

6. Items 12 to 14 – Sign and date the form. Enter your office’s mailing address.

3. Recording and forwarding the VA Form 21-4180

Upon completing the VA Form 21-4180:

• fax the completed form into the Non Disability Repository for Evidentiary Documents (NDRED). (For more information on NDRED, see GN 00301.310); and

• return the VA Form 21-4180 to the VA regional office address shown in Item 2 of the form or to the RRB, as appropriate.

F. RRB Action

If the RRB receives VA Form 21-4180 from the VA and it does not have jurisdiction in the case, RRB will send the form and any pertinent claims material to us. If RRB previously sent us claims material, RRB will send the VA Form 21-4180 to the FO servicing the address of the VA claimant.