Fillable Va Form 21p-530 - Application For Burial Benefits (Page 4 of 4) in pdf

PART III - CLAIM FOR PLOT OR INTERMENT ALLOWANCE

16. PLACE OF BURIAL OR LOCATION OF DECEASED VETERAN'S REMAINS

17. WAS VETERAN BURIED IN A NATIONAL CEMETERY OR ONE OWNED BY THE

(Specify)

FEDERAL GOVERNMENT?

YES

18B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION

18A. DID A FEDERAL/STATE GOVERNMENT OR THE

VETERAN'S EMPLOYER CONTRIBUTE TO THE BURIAL?

YES

(If "Yes," complete Item 18B)

PART IV - CLAIM FOR TRANSPORTATION REIMBURSEMENT

19. EXPENSES INCURED FOR THE TRANSPORTATION OF THE VETERAN'S REMAINS FROM THE PLACE OF DEATH TO THE FINAL RESTING PLACE

(Attach itemized receipts)

PART V - CERTIFICATION AND SIGNATURE

I CERTIFY THAT the foregoing statements made in connection with this application on account of the named veteran are true and correct to the best of my knowledge

and belief.

20A. SIGNATURE OF CLAIMANT (If signed using an "X", complete Items 24A thru 25B)

20B. OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM,

(If signing for firm, corporation, or State agency, complete Items 20B thru 21)

CORPORATION OR STATE AGENCY

21. FULL NAME AND ADDRESS OF THE FIRM, CORPORATION, OR STATE AGENCY FILING AS CLAIMANT

NOTE - Where the claimant is a firm, corporation or State agency, Items 22A thru 25 MUST be completed by the individual who authorized services.

I CERTIFY THAT the foregoing statements made by the claimant are correct to the best of my knowledge and belief.

22A. SIGNATURE OF PERSON WHO AUTHORIZED SERVICES

22B. DATE

22C. NAME AND TITLE OF PERSON AUTHORIZING SERVICES (Type or Print)

23. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

WITNESS TO SIGNATURE IF MADE BY "X"

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

signatures and addresses of such witnesses must be shown below.

24A. SIGNATURE OF WITNESS

24B. ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS

25B. ADDRESS OF WITNESS

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

knowing it to be false.

DEPARTMENT OF VETERANS AFFAIRS HEADSTONES AND MARKERS

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 of

certain individuals eligible for burial in a national cemetery, but not buried there. These individuals may include any veterans with an other than dishonorable discharge

who dies after service or any servicemember who dies on active duty. Certain other individuals may also be eligible for the headstone or marker. Headstones or markers

for all individuals in a national or post cemetery are furnished automatically without request from the family.

For additional information on burial benefits go to the web site, To obtain VA Form 40-1330, Application for Standard

Government Headstone or Marker go to

or contact your local VA regional office. The address of that office can be found at to

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VA FORM 21P-530, JUN 2014