Mdva Hgr - Military Funeral Honors Stipend Request Page 2
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3Military Funeral Honors Stipend Request
A Veterans Service Organization (VSO) should submit this form to request a stipend for performing military
funeral honors. The responsibility for proper completion and submission of this form rests with the VSO.
Stipend will not exceed $50.00 from the Minnesota Department of Veterans Affairs and/or an additional
$50.00 from the Minnesota National Guard for each honors being provided.
• All requests must be submitted within 45 days of honors being provided.
• The VSO is responsible for obtaining the mandatory signatures from the Honor Guard Leader, Funeral
Director and ARNG Honor Guard Coordinator.
• Service for each veteran should be verified by DD-214. Do not submit a DD-214 with this form.
PART ONE: VSO Performing Honors
Charitable Gambling (check one) yes
no
Honor Guard Unit: ______________________________________ Vendor #: __________________
Point of Contact (please print): _____________________________
Phone #:__________________
Address: __________________________________
City: ________________
Zip: _________
Honors performed (check box that apply):
Full Honors (Rifle Detail, Taps, Flag Folding)
Basic Honors (Flag Folding, Taps)
Signature of Honor Guard Leader: _________________________________ Date: ______________
PART TWO: Information – Deceased Veteran
DD-214 Form Confirmed
Name of Veteran: ___________________________________________________________________
Date Honors Performed: ____________________
Date of Birth: ___________________
Location of Honors:
City: __________________________ County: ______________________
Branch of Service:
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard
Reserves
National Guard Stipend Only: Verifier #1: _________________________ SSN: _______________
Verifier #2: _________________________ SSN: _______________
PART THREE: Funeral Director Verification
Were the military honors performed in an acceptable manner?
Yes
No
(Contact Bastian C. VanHofwegen, ARNG Honor Guard Coordinator, with any comments)
Name of Funeral Home: _____________________________________________________________
City: ___________________________________________
Phone #: ______________________
Printed Name: _____________________________________________________________________
Signature: __________________________________________
Date: ___________________
Mail or fax the form to: Bastian C. VanHofwegen, ARNG Honor Guard Coordinator, Veterans
th
Service Bldg, 20 West 12
St, St Paul, MN 55155. Office: (651) 282-4570 Fax: (651) 282-4125
For Office Use Only
PAYMENT INFORMATION
Amount:
_________
Input Date:
__________
Trans #:
________________
Entered By ____________
ARNG Honor Guard Coordinator Approval:______________________________________
Date: ______________
MDVA HGR (02/08)
You can print this form from the MDVA website at
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