Form 21-530 Application for Burial Benefits

c VETERAN'S ESTATE If the expenses were paid from the veteran's estate the claim should be filed by the executor/ (1 FIRST MIDDLE LAST NAME OF DECEASED VETERAN ) (1) Expenses incurred for the plot or interment if burial was not in a national cemetery or other cemetery under the (1) The veteran died of a service connected disability or had a compensable service connected disability and burial is in a (10 IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1 GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME ) (12 PLACE OF BURIAL OR LOCATION OF CREMAINS ) (16 IF PLOT/INTERMENT EXPENSES ARE UNPAID WHO WILL FILE CLAIM FOR EXPENSES? (Name and Address) ) (17 TOTAL EXPENSE OF BURIAL FUNERAL TRANSPORTATION AND IF CLAIMED BURIAL PLOT ) (18 AMOUNT PAID ) (19 WHOSE FUNDS WERE USED?) (2 SOCIAL SECURITY NUMBER OF VETERAN ) (2) Expenses payable to a State (or political subdivision) if the veteran died from non service connected causes and was (2) The veteran died while in a hospital domiciliary or nursing home to which he/she had been properly admitted under (20B AMOUNT OF REIMBURSEMENT ) (20C SOURCE OF REIMBURSEMENT ) (21B AMOUNT ) (21C SOURCE(S) ) (24 PLACE OF BURIAL OR LOCATION OF CREMAINS ) (25A COST OF BURIAL PLOT (Individual Grave Site Mausoleum Vault or Columbarium Niche) ) (25B DATE OF PURCHASE Enter 2 digit month 2 digit day and 4 digit year ) (25C DATE OF PAYMENT Enter 2 digit month 2 digit day and 4 digit year ) (26B AMOUNT PAID ) (27 WHOSE FUNDS WERE USED?) (28B AMOUNT OF REIMBURSEMENT ) (28C SOURCE OF REIMBURSEMENT ) (29B AMOUNT ) (29C SOURCE ) (3 VA FILE NUMBER ) (3) The veteran died en route while traveling under prior authorization of VA for the purpose of examination treatment or care (30A SIGNATURE OF CLAIMANT (If signed using an "X" complete Items 36A thru 37B) (If signing for firm corporation or State agency complete Items 30B thru 31) THIS IS A PROTECTED FIELD ) (30B OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM CORPORATION OR STATE AGENCY ) (31 FULL NAME AND ADDRESS OF THE FIRM CORPORATION OR STATE AGENCY FILING AS CLAIMANT ) (32A SIGNATURE OF PERSON WHO AUTHORIZED SERVICES (If signed using an "X" complete Items 36A thru 37B) THIS IS A PROTECTED FIELD ) (32B NAME OF PERSON AUTHORIZING SERVICES (Type or Print) ) (33 ADDRESS (Number and street or rural route city or P O State and ZIP Code) ) (34 DATE Enter 2 digit month 2 digit day and 4 digit year ) (35 RELATIONSHIP TO VETERAN ) (36A SIGNATURE OF WITNESS THIS IS A PROTECTED FIELD ) (36B ADDRESS OF WITNESS ) (37A SIGNATURE OF WITNESS THIS IS A PROTECTED FIELD ) (37B ADDRESS OF WITNESS ) (4 FIRST MIDDLE LAST NAME OF CLAIMANT ) (5A TELEPHONE NUMBER(S) (Include Area Code) DAYTIME ) (5B TELEPHONE NUMBER(S) (Include Area Code) EVENING ) (5C E MAIL ADDRESS ) (6A MAILING ADDRESS OF CLAIMANT (Number and street or rural route city or P O State and ZIP Code) ) (6B IF CLAIMANT IS A FUNERAL HOME PROVIDE THE EMPLOYER IDENTIFICATION NUMBER (EIN)) (7A DATE OF BIRTH Enter 2 digit month 2 digit day and 4 digit year ) (7B PLACE OF BIRTH ) (8A DATE OF DEATH Enter 2 digit month 2 digit day and 4 digit year ) (8B PLACE OF DEATH ) (8C DATE OF BURIAL Enter 2 digit month 2 digit day and 4 digit year ) (8D WHERE DID THE VETERAN'S DEATH OCCUR? OTHER (Specify) ) (9A ENTERED SERVICE DATE Enter 2 digit month 2 digit day and 4 digit year LINE 1 OF 3 ) (9A ENTERED SERVICE DATE Enter 2 digit month 2 digit day and 4 digit year LINE 2 OF 3 ) (9A ENTERED SERVICE DATE Enter 2 digit month 2 digit day and 4 digit year LINE 3 OF 3 ) (9A ENTERED SERVICE PLACE ) (9A ENTERED SERVICE PLACE ) (9B SERVICE NUMBER ) (9B SERVICE NUMBER ) (9C SEPARATED FROM SERVICE DATE Enter 2 digit month 2 digit day and 4 digit year ) (9C SEPARATED FROM SERVICE DATE Enter 2 digit month 2 digit day and 4 digit year ) (9C SEPARATED FROM SERVICE PLACE ) (9C SEPARATED FROM SERVICE PLACE ) (9D GRADE RANK OR RATING ORGANIZATION AND BRANCH OF SERVICE ) (9D GRADE RANK OR RATING ORGANIZATION AND BRANCH OF SERVICE ) (DO NOT WRITE IN THIS SPACE) (IF "No " complete Items 15 and 16) (If "No " complete Items 15 and 16)YESNO15 BURIAL PLOT MAUSOLEUM VAULT COLUMBARIUM NICHE ETC (If "Yes " complete Items 20B and 20C)YESNO20B AMOUNT OF REIMBURSEMENT$ (If "Yes " complete Items 21B and 21C)YESNO$ (If "Yes "complete Items 28B and 28C)YESNO28B AMOUNT OF REIMBURSEMENT$ (If "Yes "complete Items 29B and 29C)YESNO29A HAS ANY AMOUNT BEEN OR WILL ANY AMOUNT (If signing for firm corporation or State agency complete Items 30B thru 31) (Under 38 U S C Chapter 23) (VA DATE STAMP) 1 800 827 1000 to get information on where to send comments or suggestions about this form 1 FIRST MIDDLE LAST NAME OF DECEASED VETERAN 1 GENERAL 10 IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1 GIVE FULL NAME AND 10 WHERE DO I MAIL MY COMPLETED APPLICATION? You should mail your application to the VA regional office located 11 ARE YOU CLAIMING THAT THE CAUSE OF 14 WAS BURIAL IN A NATIONAL CEMETERY 17 TOTAL EXPENSE OF BURIAL FUNERAL TRANSPORTATION 18 AMOUNT PAID$ 19 WHOSE FUNDS WERE USED? 2 SOCIAL SECURITY NUMBER OF VETERAN 2 WHO SHOULD FILE A CLAIM 2 year limitation does not apply to service connected burial benefits transportation expenses or reimbursement of headstone expenses 20A HAS THE PERSON WHOSE FUNDS WERE USED BEEN 20C SOURCE OF REIMBURSEMENT 21 530 21 530Page 3 21A HAS ANY AMOUNT BEEN OR WILL ANY AMOUNT BE 21B AMOUNT 21C SOURCE(S) 22 WAS THE VETERAN A MEMBER OF A BURIAL ASSOCIATION OR COVERED BY BURIAL INSURANCE? 23 WAS BURIAL (WITHOUT CHARGE FOR PLOT OR INTERMENT) IN 25A COST OF BURIAL PLOT(Individual Grave Site Mausoleum Vault or 25B DATE OF PURCHASE 25C DATE OF PAYMENT 26A HAVE BILLS BEEN PAID IN FULL? 26B AMOUNT PAID$ 27 WHOSE FUNDS WERE USED? 28A HAS PERSON WHOSE FUNDS WERE USED BEEN 28C SOURCE OF REIMBURSEMENT 29B AMOUNT 29C SOURCE 3 TIME LIMIT FOR FILING A CLAIM A claim for non service connected burial expenses or plot allowance must be filed 3 VA FILE NUMBER 30A SIGNATURE OF CLAIMANT(If signed using an "X" complete Items 36A thru 37B) 30B OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM 31 FULL NAME AND ADDRESS OF THE FIRM CORPORATION OR STATE AGENCY FILING AS CLAIMANT 32A SIGNATURE OF PERSON WHO AUTHORIZED SERVICES (If signed using an "X" 32B NAME OF PERSON AUTHORIZING SERVICES (Type or Print) 33 ADDRESS(Number and street or rural route city or P O State and ZIP Code) 34 DATE 35 RELATIONSHIP TO VETERAN 36A SIGNATURE OF WITNESS 36B ADDRESS OF WITNESS 37A SIGNATURE OF WITNESS 37B ADDRESS OF WITNESS 4 COMPLETING CLAIM BY A FIRM OR STATE AGENCY The claim must be executed in the full name of the firm or 4 FIRST MIDDLE LAST NAME OF CLAIMANT 5 PROOF OF DEATH TO ACCOMPANY CLAIM Death in a government institution does not need to be proven In other 5 TELEPHONE NUMBER(S)(Include Area Code)5C E MAIL ADDRESS 6 STATEMENT OF ACCOUNT MUST ACCOMPANY CLAIM 6A MAILING ADDRESS OF CLAIMANT (Number and street or rural route city or P O State and ZIP Code) 6B IF CLAIMANT IS A FUNERAL HOME PROVIDE THE EMPLOYER IDENTIFICATION NUMBER (EIN) 7 BURIAL ASSOCIATION OR BURIAL INSURANCE If the veteran was a member of a burial association or if any insurance 7B PLACE OF BIRTH 8 SERVICE RECORD The original or certified copy of the veteran's service separation document (DD214 or equivalent) 8A DATE OF DEATH 8B PLACE OF DEATH 8C DATE OF BURIAL 8D WHERE DID THE VETERAN'S DEATH OCCUR? (Check one) 9 TOLL FREE TELEPHONE ASSISTANCE You can call us toll free within the U S by dialing 1 800 827 1000 If you 9A ENTERED SERVICE9B SERVICE a BURIAL ALLOWANCE An amount towards the expenses of the funeral and burial of the veteran's remains Burial a CREDITOR If expenses have not been paid the claim should be filed by the funeral director or crematory service by A DAYTIME a FUNERAL DIRECTOR A statement of account on the funeral director's letterhead must show the name of the veteran; A STATE OWNED CEMETERY OR SECTION THEREOF USED SOLELY FOR administrator by completing Parts I II and IV Submit a copy of the letters of administration or letters testamentary certified AGENCY? ALLOWED ON EXPENSES BY LOCAL STATE OR FEDERAL and complete this form VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed AND IF CLAIMED BURIAL PLOT$ and the name of the person or persons by whom payment in whole or in part was made APPLICATION FOR BURIAL BENEFITS are located in the local dialing area of a VA regional office you can also call us by checking your local telephone directory For the authority of VA; OR B EVENING b PERSON WHOSE FUNDS WERE USED If all creditors have been paid the claim should be filed by the person or b PLOT ALLOWANCE Plot means the final resting place of the remains The allowance is payable towards: b TRANSPORTATION If transported by common carrier a receipt must accompany the claim All receipts for BE ALLOWED ON EXPENSES BY STATE OR FEDERAL buried in a State owned cemetery or section used solely for the remains of persons eligible for burial in a national c ACCOUNT PAID IN FULL The statement of account should be receipted in the name of the firm or individual performing c BURIAL ALLOWANCE FOR SERVICE CONNECTED DEATH When the veteran's death occurred as the result of a cases the claimant must forward a copy of the public record of death If proof has previously been furnished VA it need not be cemetery cemetery or section used for persons eligible in a national cemetery the claim may be filed by the State official completing Columbarium Niche) company is obligated to pay all or part of the burial expenses Item 22 should be answered "Yes " It will be necessary to support complete Items 36A thru 37B) completing Parts I II and IV If the funeral director or crematory service has paid or advanced funds for or furnished the completing Parts I III and IV If both the funeral director and cemetery owner are unpaid each must submit a separate computer matching programs with other agencies CORPORATION OR STATE AGENCY COST IS: (CHECK ONE) d PLOT ALLOWANCE ONLY In a claim for the plot allowance only the statement of account must show the cost of the d STATE If a veteran whose death is non service connected was buried without charge for plot or interment in a State owned d TRANSPORTATION EXPENSES The cost of transporting the body to the place of burial may be paid in addition to death to "Under Conditions Other Than Dishonorable " the claim must be filed within 2 years from the date of correction The DEATH WAS DUE TO SERVICE? delay or payment of a lesser amount Department of Veterans Affairs DEPARTMENT OF VETERANS AFFAIRS HEADSTONES AND MARKERS determine maximum benefits under the law and is required to obtain benefits Information submitted is subject to verification through directory The address is also located in the government pages of your telephone book under "United States Government Veterans " discharge who dies after service or any serviceman or servicewoman who dies on active duty Certain other individuals may also be eligible for the headstone or DUE CEMETERY OWNERPAID BY ANOTHER PERSON(S) DUE FUNERAL DIRECTORNONEPAID BY CLAIMANT FOR BURIAL16 IF PLOT/INTERMENT EXPENSES ARE UNPAID WHO WILL FILE CLAIM FOR ELIGIBLE FOR BURIAL IN A NATIONAL CEMETERY? Employment Records VA published in the Federal Register The requested information is considered relevant and necessary to EXISTING STOCKS OF VA FORM 21 530 EXPENSES?(Name and Address) For additional information on burial benefits go to the web site www cem va gov/bbene burial asp To obtain VA Form 40 1330 Application for Standard gov/directory Government Headstone or Marker go to www va gov/vaformsor contact your local VA regional office The address of that office can be found at to www va GOVERNMENT? hearing impaired our TDD number is 1 800 829 4833 I CERTIFY THAT the foregoing statements made by the claimant are correct to the best of my knowledge and belief identified in the VA system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and If cemetery owner or other creditor has not been paid for the plot and related interment expenses he/she may file claim by IMPORTANT Complete only if burial was NOT in a national cemetery or cemetery owned by the Federal Government IMPORTANT Read instructions carefully before completing form YOUR COMPLIANCE WITH ALL IMPORTANT READ THESE INSTRUCTIONS CAREFULLY in your state You can obtain the mailing address for VA regional offices by accessing the VA Internet web site at www va gov/ includes all recognized methods of interment INSTRUCTIONS FOR COMPLETING APPLICATION FOR BURIAL BENEFITS (UNDER 38 U S C CHAPTER 23) INSTRUCTIONS WILL AVOID DELAY Type or print all information INTERMENT) IN A STATE OWNED CEMETERY OR JAN 2010 WILL BE USED jurisdiction of the United States; OR knowing it to be false marker Headstones or markers for all individuals in a national or post cemetery are furnished automatically without request from the family MAY 2012 MAY 2012JAN 2010 WILL BE USED national cemetery; OR NOTE If claimant signed above using an "X" signature must be witnessed by two persons to whom the person making the statement is personally known and the NOTE If claiming Plot Allowance Only do not complete Part II but complete Parts III and IV on page 4 12 PLACE OF BURIAL OR LOCATION OF CREMAINS NOTE Where the claimant is a firm or other unpaid creditor Items 32A thru 35 MUST be completed by the individual who authorized services NUMBER9C SEPARATED FROM SERVICE9D GRADE RANK OR RATING of certain individuals eligible for burial in a national cemetery but not buried there These individuals include any veteran with an other than dishonorable OMB Approved No 2900 0003 OR CEMETERY OWNED BY THE FEDERAL ORGANIZATION AND BRANCH OF SERVICEDATEPLACEDATEPLACE outside the Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act including the routine uses over the signature and seal of the appointing court Page 1 Page 2 Page 4 PART I INFORMATION REGARDING VETERAN7A DATE OF BIRTH PART III CLAIM FOR PLOT COST ALLOWANCE PART IV CERTIFICATION AND SIGNATUREI CERTIFY THAT the foregoing statements made in connection with this application on account of the named veteran are true and correct to Parts I III (Items 23 and 24) and IV PENALTY The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact PERSONS ELIGIBLE FOR BURIAL IN A NATIONAL CEMETERY? persons whose personal funds were used by completing Parts I II and IV plot or interment expenses inclusion of these items on the statement of account will serve as claim for the plot allowance PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U S C 5701) They may be disclosed REIMBURSED? Respondent Burden: 22 minutes RESPONDENT BURDEN: We need this information to determine your eligibility burial benefits Title 38 United States Code allows SECTION THEREOF USED SOLELY FOR PERSONS service connected disability a special "service connected" rate is payable SERVICE INFORMATION(The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE) SERVICE RENDERED UNDER THAT NAME signatures and addresses of such witnesses must be shown below State agency and show the official position or connection of the individual who signs on its behalf submitted again the best of my knowledge and belief the burial allowance when: the claim with a statement from the association or insurance company setting forth the terms of the contract and how and with The Department of Veterans Affairs will furnish upon request a Government headstone or marker at the expense of the United States for the unmarked graves The itemized statement of account should show the charges made for transportation Failure to itemize charges may result in the nature and cost of services including any payments made to another funeral home (show name and address); all credits; the services Bills or receipts filed in support of this claim become a part of the permanent record and will not be returned transportation charges should show the name of the veteran the name of the person who paid and the amount of the charges unless specifically requested us to ask for this information We estimate that you will need an average of 22 minutes to review the instructions find the information VA FORM VA FORM 21 530 MAY 2012 VA Form 21 530 signed by the person who authorized services VA FORM EXISTING STOCKS OF VA FORM 21 530 VA MEDICAL CENTERSTATE VETERANS HOMENURSING HOME UNDER VA CONTRACTOTHER (Specify) Valid OMB control numbers can be located on the OMB Internet Page at www reginfo gov/public/do/PRAMain If desired you can call veteran's individual grave site the mausoleum vault or the columbarium niche which contains information as to the length time and character of service will permit prompt processing whom settlement was made with VA within 2 years from the date of the veteran's permanent burial or cremation If a veteran's discharge was corrected after WITNESS TO SIGNATURE IF MADE BY "X" YESNO(Before answering read and comply with Instruction 7 on Page 2) YESNO(If "No " complete Items 26B and 27) YESNO13 WAS BURIAL (WITHOUT CHARGE FOR PLOT OR YESNO24 PLACE OF BURIAL OR LOCATION OF CREMAINS YESNOPART II CLAIM FOR BURIAL BENEFITS AND/OR INTERMENT ALLOWANCE IF PAID BY CLAIMANT