Va Form 21-8834 - Application For Reimbursement Of Headstone Or Marker Expense

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OMB Approved No. 2900-0266

Respondent Burden: 10 Mins.

APPLICATION FOR REIMBURSEMENT OF HEADSTONE OR MARKER EXPENSE

(First, middle, last)

1. NAME OF DECEASED VETERAN

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH

5. PLACE OF BIRTH

6. DATE OF DEATH

7. PLACE OF DEATH

(Name and location)

8. DATE OF BURIAL

10. WAS VETERAN BURIED OR MEMORIAL IN A

9. PLACE OF BURIAL OR MEMORIAL

NATIONAL CEMETERY?

11. SERVICE INFORMATION

A. ENTERED SERVICE

C. SEPARATED FROM SERVICE

B. SERVICE

D. GRADE AND

E. BRANCH OF

NUMBER

ORGANIZATION

SERVICE

DATE

PLACE

DATE

PLACE

(First, middle, last)

12. NAME OF CLAIMANT

13. RELATIONSHIP TO VETERAN

14. MAILING ADDRESS OF CLAIMANT

15. AMOUNT PAID

B. ENGRAVING OR EXISTING STONE

A. HEADSTONE OR MARKER

OR MARKER

(Mo., day, yr.)

16. DATE PURCHASED

A. HEADSTONE OR MARKER

B. ENGRAVING

FOR VA USE ONLY

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 and that I have NOT

The above application has been received and is pending payment.

filed a separate application for a headstone.

17. SIGNATURE OF CLAIMANT

18. DATE

DATE RECEIVED

DATE FORWARD

RO NUMBER

INFORMATION AND INSTRUCTIONS FOR

COMPLETING APPLICATION FOR REIMBURSEMENT OF HEADSTONE OR MARKER EXPENSES

IN LIEU OF GOVERNMENT FURNISHED HEADSTONE OR MARKER

PRIVACY ACT INFORMATION: No reimbursement of headstone or marker may be granted unless this form is completed and returned as required

by law (38 U.S.C. Chapter 23). The responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you

provide outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records,

58VA21/22 Compensation, Pension, Education, and Rehabilitation Records - VA. The requested information is considered relevant and necessary to

determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with other Federal or

state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue

of your participation in any benefit program administered by VA.

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 10 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.

HOW TO APPLY. Forward this application to the Department of Veteran Affairs Regional Office nearest you.

1. Benefits Payable. In lieu of a headstone or marker furnished at government expense, an amount not to exceed the average government cost, or the

actual cost, whichever is less, of privately procured headstones or markers (excluding base) or the additional engraving of an existing headstone or

marker already in place to include the deceased's data may be paid on a reimbursable basis when the veteran is buried or memorialized in other than a

National Cemetery. NOTE: Reimbursement applies only to headstone, marker, or engraving expenses incurred and paid subsequent to the veterans

death.

VA FORM

21-8834

SUPERSEDES VA FORM 21-8834, JUL 1992,

(Continued on Reverse)