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

VETERAN'S SSN

PART II - CLAIM FOR BURIAL ALLOWANCE

(Check one)

13A. TYPE OF BURIAL ALLOWANCE REQUESTED

13B. WHERE DID THE VETERAN'S DEATH OCCUR?

NURSING HOME UNDER VA CONTRACT

VA MEDICAL CENTER

NON-SERVICE-CONNECTED DEATH

(Specify)

OTHER

STATE VETERANS HOME

SERVICE-CONNECTED DEATH

VA MEDICAL CENTER DEATH (See instructions for definition.)

(If VA Medical Center Death is checked, provide actual burial cost.)

14. IF YOU ARE THE DECEASED VETERAN'S SPOUSE, DID YOU

PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?

YES

15A. DID YOU INCUR EXPENSES FOR THE VETERAN'S BURIAL?

YES

15B. ARE YOU SEEKING BURIAL BENEFITS FOR THE UNCLAIMED REMAINS OF A VETERAN?

YES

PART III - CLAIM FOR PLOT OR INTERMENT ALLOWANCE

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

(Specify)

17A.DID YOU INCUR EXPENSES FOR THE VETERAN'S PLOT OR INTERMENT?

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

THE FEDERAL GOVERNMENT?

YES

17C. WAS THE VETERAN BURIED IN A STATE VETERANS CEMETERY?

YES

18A. DID A FEDERAL/STATE GOVERNMENT OR THE VETERAN'S

18B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION

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 (Please sign in ink. If signed using an "X", complete Items

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

24A thru 25B) (If signing for firm, corporation, or State agency, complete Items 20B thru 21)

(Please sign in ink.)

CORPORATION OR STATE AGENCY

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

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.

(Please sign in ink.)

22B. ADDRESS OF WITNESS

22A. SIGNATURE OF WITNESS

(Please sign in ink.)

23B. ADDRESS OF WITNESS

23A. SIGNATURE 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, APR 2017