Form 21p-530 - Application For Burial Benefits
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1OMB Approved No. 2900-0003
Respondent Burden: 15 Mins.
Expiration Date: 06/30/2017
(DO NOT WRITE IN THIS SPACE)
Department of Veterans Affairs
(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
Sam Cafferty
2. SOCIAL SECURITY NUMBER OF VETERAN
3. VA FILE NUMBER
--
XC/XSS -
4. FIRST, MIDDLE, LAST NAME OF CLAIMANT
Vickie Cafferty
5. TELEPHONE NUMBER(S) (Include Area Code)
6. E-MAIL ADDRESS OF CLAIMANT
A. DAYTIME
B. EVENING
(222) 222-2222
(222) 222-2222
7. MAILING ADDRESS OF CLAIMANT (Number and street or rural route, city or P.O., State and ZIP Code)
2222 Wire Way
Funkytown, PA 222222
8.RELATIONSHIP OF CLAIMANT TO DECEASED VETERAN (Check one)
EXECUTOR/ADMINISTRATOR OF ESTATE
SPOUSE
OTHER (Specify)
CHILD
PARENT
PART I - INFORMATION REGARDING VETERAN
9A. DATE OF BIRTH
9B. PLACE OF BIRTH
03/03/1933
10A. DATE OF DEATH
10B. PLACE OF DEATH
10C. DATE OF BURIAL
08/09/2012
Baton Rouge Health Care Center
08/17/2012
10D. WHERE DID THE VETERAN'S DEATH OCCUR? (Check one)
VA MEDICAL CENTER
NURSING HOME UNDER VA CONTRACT
OTHER (Specify)
STATE VETERANS HOME
SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)
11A. ENTERED SERVICE
11B. SERVICE
11C. SEPARATED FROM SERVICE
11D. GRADE, RANK OR RATING,
NUMBER
DATE
PLACE
DATE
PLACE
ORGANIZATION AND BRANCH OF SERVICE
--
--
12. IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME
PART II - CLAIM FOR BURIAL ALLOWANCE
13. BENEFITS REQUESTED (Check one)
14. IF DECEASED VETERAN'S SPOUSE, DID YOU
PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
NON-SERVICE-CONNECTED DEATH
YES
NO
SERVICE-CONNECTED DEATH
15A. DID YOU INCUR EXPENSES FOR THE VETERAN'S BURIAL OR INTERMENT?
YES
NO
15B. ARE YOU SEEKING BURIAL BENEFITS FOR A VETERAN'S NON-SERVICE-CONNECTED DEATH OCCURING AT A VA MEDICAL CENTER, NURSING HOME
UNDER VA CONTRACT, OR OTHER VA FACILITY?
YES
NO
(If " Yes," provide actual burial cost)
$
VA FORM
SUPERSEDES VA FORM 21-530, MAY 2012,
21P-530
WHICH WILL NOT BE USED
JUN 2014
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