Va Form 21-2008 - Application For United States Flag For Burial Purposes

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OMB APPROVED NO. 2900-0013

RESPONDENT BURDEN: 15 MINUTES

APPLICATION FOR UNITED STATES FLAG FOR BURIAL PURPOSES

RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB

Control Number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have

comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your

comments.

IMPORTANT - Postmaster or other issuing official: Submit this form to the nearest VA Regional Office. Be sure to complete the stub at the bottom.

1. LAST NAME - FIRST NAME-MIDDLE NAME OF DECEASED (Print or type)

2. BRANCH OF SERVICE (Check box)

3. VETERAN’S SERVICE (Check box)

ARMY

NAVY

AIR

MARINE

COAST

SPANISH

WWI

WWII

KOREAN

AFTER

VIETNAM ERA

FORCE

CORPS

GUARD

AMERICAN

CONFLICT

1-31-55

OTHER (Specify)

4. CONDITION UNDER WHICH VETERAN WAS RELEASED FROM SERVICE (Check box) (See Item 2, Instructions on Reverse)

A. VETERAN OF A WAR, MEXICAN BORDER SERVICE, OR OF SERVICE AFTER

C. BY DEATH IN ACTIVE SERVICE AFTER MAY 27, 1941,

1-31-55, DISCHARGED OR RELEASED FROM ACTIVE DUTY UNDER CONDITIONS

AND FLAG NOT FURNISHED BY THE SERVICE DEPARTMENT

OTHER THAN DISHONORABLE

D. SEPARATED FROM PHILIPPINE MILITARY FORCES, UNDER

CONDITIONS OTHER THAN DISHONORABLE, AFTER SERVING

B. DISCHARGED FROM OR RELEASED FROM ACTIVE DUTY IN U.S. ARMED FORCES

WITH THE UNITED STATES IN SUCH FORCES UNDER THE

UNDER CONDITIONS OTHER THAN DISHONORABLE, AFTER SERVING AT LEAST

PRESIDENT’S ORDER OF JULY 26, 1941, AND DIED ON OR AFTER

ONE

APRIL 25, 1951

5. NAME OF PERSON ENTITLED TO RECEIVE FLAG

6. ADDRESS OF PERSON ENTITLED TO RECEIVE FLAG

7. RELATIONSHIP TO DECEASED (See Item 1, Instructions on Reverse)

PERSONAL DATA OF DECEASED (To be completed if possible)

8. VA FILE NUMBER

9. SOCIAL SECURITY NUMBER

10. SERVICE SERIAL NUMBER

11. DATE OF ENLISTMENT

12. DATE OF DISCHARGE

13. DATE OF BIRTH

14. DATE OF DEATH

15. DATE OF BURIAL

16. PLACE OF BURIAL (Name of cemetery, city, and State)

17. REMARKS

I CERTIFY that, to the best of my knowledge and belief, the statements made above are correct and true, the deceased is eligible, in accordance with instructions on

reverse for issue of a United States flag for burial purposes, and such flag has not previously been applied for or furnished.

18. SIGNATURE OF APPLICANT (Sign in INK)

19. ADDRESS OF APPLICANT ( Number and street or

20. RELATIONSHIP TO DECEASED

21. DATE SIGNED

rural route, city or P.O., and ZIP Code)

PENALTY - The law provides that whoever makes any statement of a material fact knowing it to be false shall be punished by a fine or both imprisonment or both.

ACKNOWLEDGMENT OF RECEIPT OF FLAG

I CERTIFY that the flag requested by the applicant will be used to drape the casket of the deceased in whose honor it is issued by the Department of Veterans Affairs;

and that Item 6 of the Instructions will be complied with.

SIGNATURE OF PERSON RECEIVING FLAG (Sign in INK)

DATE FLAG RECEIVED

NAME AND ADDRESS OF POST OFFICE OR OTHER FLAG ISSUE POINT

FOR VA USE

DATE NOTIFICATION

INITIALS OF RESPONSIBLE

FORWARDED TO SUPPLY

VA EMPLOYEE

VA FORM

EXISTING STOCK OF VA FORM 2008, SEP 1993(R),

21-2008