Va Form 21p-530 - Application For Burial Benefits Page 3
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4OMB Approved No. 2900-0003
Respondent Burden: 15 Minutes
Expiration Date: 06/30/2017
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
APPLICATION FOR BURIAL BENEFITS
(Under 38 U.S.C. Chapter 23)
IMPORTANT - Read instructions carefully before completing form. YOUR COMPLIANCE WITH ALL
INSTRUCTIONS WILL AVOID DELAY. Type or print all information.
1. FIRST, MIDDLE, LAST NAME OF DECEASED VETERAN
2. SOCIAL SECURITY NUMBER OF VETERAN
3. VA FILE NUMBER
4. FIRST, MIDDLE, LAST NAME OF CLAIMANT
(Include Area Code)
5. TELEPHONE NUMBER(S)
6. E-MAIL ADDRESS OF CLAIMANT
A. DAYTIME
B. EVENING
(Number and street or rural route, city or P.O., State and ZIP Code)
7. MAILING ADDRESS OF CLAIMANT
(Check one)
8. RELATIONSHIP OF CLAIMANT TO DECEASED VETERAN
SPOUSE
EXECUTOR/ADMINISTRATOR OF ESTATE
(Specify)
CHILD
OTHER
PARENT
PART I - INFORMATION REGARDING VETERAN
9A. DATE OF BIRTH
9B. PLACE OF BIRTH
10A. DATE OF DEATH
10B. PLACE OF DEATH
10C. DATE OF BURIAL
(Check one)
10D. WHERE DID THE VETERAN'S DEATH OCCUR?
VA MEDICAL CENTER
NURSING HOME UNDER VA CONTRACT
(Specify)
STATE VETERANS HOME
OTHER
SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)
11A. ENTERED SERVICE
11C. SEPARATED FROM SERVICE
11B. SERVICE
11D. GRADE, RANK OR RATING,
NUMBER
ORGANIZATION AND BRANCH OF SERVICE
DATE
PLACE
DATE
PLACE
12. IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME
PART II - CLAIM FOR BURIAL ALLOWANCE
14. IF DECEASED VETERAN'S SPOUSE, DID YOU
(Check one)
13. BENEFITS REQUESTED
PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
NON-SERVICE-CONNECTED DEATH
YES
NO
SERVICE-CONNECTED DEATH
15A. DID YOU INCUR EXPENSES FOR THE VETERAN'S BURIAL OR INTERMENT?
YES
NO
15B. ARE YOU SEEKING BURIAL BENEFITS FOR A VETERAN'S NON-SERVICE-CONNECTED DEATH OCCURING AT A VA MEDICAL CENTER, NURSING HOME
UNDER VA CONTRACT, OR OTHER VA FACILITY?
(If "Yes," provide actual burial cost)
$
YES
NO
21P-530
SUPERSEDES VA FORM 21-530, MAY 2012,
VA FORM
Page 3
WHICH WILL NOT BE USED
JUN 2014
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