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: 04/30/2020
APPLICATION FOR BURIAL BENEFITS
(Under 38 U.S.C. Chapter 23)
(DO NOT WRITE IN THIS SPACE)
IMPORTANT - Read instructions carefully before completing form. YOUR
(VA DATE STAMP)
COMPLIANCE WITH ALL INSTRUCTIONS WILL AVOID DELAY. Type or print all
information.
NOTE: You can either complete the form online or by hand. Please print information
using blue or black ink, neatly, and legibly to help process the form.
PART I - PERSONAL INFORMATION
1. FIRST, MIDDLE, LAST NAME OF DECEASED VETERAN'S NAME
3. VA FILE NUMBER
2. VETERAN'S SOCIAL SECURITY NUMBER
C/CSS -
CLAIMANT'S PERSONAL INFORMATION
4. CLAIMANT'S NAME (First, middle initial, last)
5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
6. PREFERRED TELEPHONE NUMBER (Include Area Code)
7. PREFERRED E-MAIL ADDRESS
(Check one)
8. RELATIONSHIP OF CLAIMANT TO DECEASED VETERAN
EXECUTOR/ADMINISTRATOR OF ESTATE OR PERSON ACTING FOR THE ESTATE
SPOUSE
(Specify)
CHILD
OTHER
PARENT
PART II - INFORMATION REGARDING VETERAN
9A. DATE OF BIRTH
9B. PLACE OF BIRTH
10A. DATE OF DEATH
10B. PLACE OF DEATH
10C. DATE OF BURIAL
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
VA FORM
SUPERSEDES VA FORM 21P-530, JUN 2015,
Page 3
21P-530
APR 2017
WHICH WILL NOT BE USED
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