Va Form 21- 8834 - Application For Reimbursement Of Headstone Or Marker Expense
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1
2OMB Approved No. 2900-0266
Respondent Burden: 10 Mins.
APPLICATION FOR REIMBURSEMENT OF HEADSTONE OR MARKER EXPENSE
(First, middle, last)
2. SOCIAL SECURITY NUMBER
1. NAME OF DECEASED VETERAN
3. VA FILE NUMBER
4. DATE OF BIRTH
5. PLACE OF BIRTH
6. DATE OF DEATH
7. PLACE OF DEATH
(Name and location)
9. PLACE OF BURIAL OR MEMORIAL
10. WAS VETERAN BURIED OR MEMORIAL IN A
8. DATE OF BURIAL
NATIONAL CEMETERY?
II. 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)
13. RELATIONSHIP TO VETERAN
12. NAME OF CLAIMANT
14. MAILING ADDRESS OF CLAIMANT
15. AMOUNT PAID
A. HEADSTONE OR MARKER
B. ENGRAVING OR EXISTING STONE
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
The above application has been received and is pending payment.
NOT filed a separate application for a headstone.
DATE RECEIVED
RO NUMBER
17. SIGNATURE OF CLAIMANT
18. DATE
DATE FORWARD
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
SUPERSEDES VA FORM 21-8834, JUL 1992,
21- 8834
(Continued on Reverse)
AUG 2002
WHICH WILL NOT BE USED.
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