Va Form 21-530 - Application For Burial Benefits (Page 3 of 4) in pdf

OMB Approved No. 2900-0003

Respondent Burden: 22 minutes

(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)

5C. E-MAIL ADDRESS

5. TELEPHONE NUMBER(S)

A. DAYTIME

B. EVENING

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

6A. MAILING ADDRESS OF CLAIMANT

6B. IF CLAIMANT IS A FUNERAL HOME PROVIDE THE EMPLOYER IDENTIFICATION NUMBER (EIN)

PART I - INFORMATION REGARDING VETERAN

7A. DATE OF BIRTH

7B. PLACE OF BIRTH

8A. DATE OF DEATH

8B. PLACE OF DEATH

8C. DATE OF BURIAL

(Check one)

8D. 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)

9C. SEPARATED FROM SERVICE

9A. ENTERED SERVICE

9B. SERVICE

9D. GRADE, RANK OR RATING,

NUMBER

ORGANIZATION AND BRANCH OF SERVICE

DATE

PLACE

DATE

PLACE

10. IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND

11. ARE YOU CLAIMING THAT THE CAUSE OF

SERVICE RENDERED UNDER THAT NAME

DEATH WAS DUE TO SERVICE?

YES

PART II - CLAIM FOR BURIAL BENEFITS AND/OR INTERMENT ALLOWANCE IF PAID BY CLAIMANT

NOTE - If claiming Plot Allowance Only, do not complete Part II, but complete Parts III and IV on reverse.

12. PLACE OF BURIAL OR LOCATION OF CREMAINS 13. WAS BURIAL (WITHOUT CHARGE FOR PLOT OR

14. WAS BURIAL IN A NATIONAL CEMETERY

INTERMENT) IN A STATE OWNED CEMETERY, OR

OR CEMETERY OWNED BY THE FEDERAL

SECTION THEREOF, USED SOLELY FOR PERSONS

GOVERNMENT?

ELIGIBLE FOR BURIAL IN A NATIONAL CEMETERY?

(IF "No," complete Items 15 and 16)

(If "No," complete Items 15 and 16)

YES

15. BURIAL PLOT, MAUSOLEUM VAULT, COLUMBARIUM NICHE, ETC.

16. IF PLOT/INTERMENT EXPENSES ARE UNPAID, WHO WILL FILE CLAIM FOR

COST IS: (CHECK ONE)

EXPENSES? (Name and Address)

PAID BY ANOTHER PERSON(S)

PAID BY CLAIMANT FOR BURIAL

DUE FUNERAL DIRECTOR

NONE

DUE CEMETERY OWNER

17. TOTAL EXPENSE OF BURIAL, FUNERAL, TRANSPORTATION,

18. AMOUNT PAID

19. WHOSE FUNDS WERE USED?

AND IF CLAIMED, BURIAL PLOT

20A. HAS PERSON WHOSE FUNDS WERE USED BEEN

20B. AMOUNT OF REIMBURSEMENT

20C. SOURCE OF REIMBURSEMENT

REIMBURSED?

(If "Yes," complete Items 20B and 20C)

YES

(Continued on Reverse)

VA FORM

EXISTING STOCKS OF VA FORM 21-530,

21-530

JAN 2010

NOV 2008, WILL BE USED

Va Form 21-530 - Application For Burial Benefits Page 3

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