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

OMB APPROVED NO. 2900-0013

RESPONDENT BURDEN: 15 MINUTES

APPLICATION FOR UNITED STATES FLAG FOR BURIAL PURPOSES

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine

uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an

interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22, Compensation, Pension,

Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us the veteran's SSN account information is voluntary. Refusal to

provide the veteran's SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law

in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine entitlement to benefits under the law. The responses you submit are considered confidential (38

U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine eligibility for issuance of a burial flag to a family member or friend of a deceased veteran (38 U.S.C. 2301). Title 38, United States Code, allows us to ask

for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid

OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at

If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

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

INFORMATION ABOUT THE DECEASED VETERAN (Complete as much as possible)

1. FIRST, MIDDLE, LAST NAME OF VETERAN (Print or type)

2. OTHER NAMES USED BY VETERAN (Print or type)

3. VA FILE NUMBER

4. SOCIAL SECURITY NUMBER

5. MILITARY SERVICE NUMBER/SERIAL NUMBER

6. BRANCH OF SERVICE (Check box)

ARMY

NAVY

AIR FORCE

MARINE CORPS

COAST GUARD

SELECTED SERVICE

OTHER (Specify)

7. DATE ENTERED ACTIVE DUTY (or Selected

8. DATE RELEASED FROM ACTIVE DUTY (or

9. DATE OF BIRTH

10. DATE OF DEATH

Reserve)

Selected Reserve)

11. DATE OF BURIAL

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

13. HAS DOCUMENTATION BEEN PRESENTED OR ATTACHED THAT SHOWS THE VETERAN MEETS THE ELIGIBILITY CRITERIA? (See Paragraphs C, D, and E of the

"Instructions")

YES

(If "No," explain in Item 15, "Remarks" (See paragraph E of the "Instructions"))

INFORMATION ABOUT THE FLAG RECIPIENT AND APPLICANT

14A. NAME OF PERSON ENTITLED TO RECEIVE FLAG

14B. ADDRESS OF PERSON ENTITLED TO RECEIVE FLAG (Number and street or rural

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

14C. RELATIONSHIP TO VETERAN (See Paragraph F of the "Instructions")

15. REMARKS

I CERTIFY that the statements made in this document are true and complete to the best of my knowledge. I further certify that the deceased veteran is eligible, in accordance with the attached

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

16. SIGNATURE OF APPLICANT (Sign in INK)

17. ADDRESS OF APPLICANT (Number and street or rural

18. RELATIONSHIP TO DECEASED

19. DATE SIGNED

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, 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 "Use Of The Flag" instructions on the attached sheet 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 21-2008, SEP 2005

SUPERSEDES VA FORM 21- 2008, MAY 2003, WHICH WILL NOT BE USED.

This stub is to be completed by the POSTMASTER or other issuing official. Upon receipt the VA Regional Office will detach and forward it to