Form 40-10088 Casket/Urn Reimbursement

Form Approved, OMB No.
Expiration Date: Xxx, 20XX
Respondent Burden:

REQUEST FOR REIMBURSEMENT OF CASKET/URN

(For a deceased Veteran with no next-of-kin and insufficient resources available for VA National Cemetery burial)
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average XX minutes per response. Statutory
authority for burial in a VA national cemetery is 38 U.S.C. 2402 with consideration of statutory bars to burial under 38 U.S.C. 2411. Statutory authority
for casket or urn reimbursement is 38 U.S.C. 2306, effective January 10, 2014, for deaths occurring on or after January 10, 2014. The information
requested is approved under OMB Control Number XXXX-XXXX, and is necessary to allow a person authorized to arrange for burial for the decedent to
request burial in a VA national cemetery. The National Cemetery Administration does not give, sell or transfer any personal information outside of the
agency. VA may not conduct or sponsor, and you are not required to respond to this collection of information unless it displays a valid OMB Control
Number. Responding to this collection is voluntary.
PRIVACY ACT INFORMATION: VA is asking you to provide the information on this form under 38 U.S.C. Sections 2402 and 2306 in order for VA
to determine burial eligibility of the deceased Veteran and to obtain information sufficient to provide reimbursement for the purchase of a casket or an
urn, if that Veteran has no next-of-kin and insufficient resources for burial. VA may disclose the information that you put on the form as permitted by
law. VA may make a "routine use" disclosure of the information as outlined in the applicable Privacy Act system of records notice (48VA40B, Veterans
(Deceased) Headstone or Marker Records - VA, as published in the Federal Register on August 26, 1975, (40 FR 38095)). Providing the requested
information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for reimbursement.
VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized
or required by law.

PART I - INSTRUCTIONS FOR REQUESTING BURIAL

APPLICABILITY: VA must first establish eligibility for burial for a deceased Veteran in a VA national cemetery prior to adjudicating a request for
casket/urn reimbursement. VA determinations about a Veteran's burial eligibility are distinct from determinations about entitlement to a claimed
reimbursement. The eligibility criteria for reimbursement for casket and urns are stated in 38 U.S.C. §2306, effective January 10, 2014, for deaths
occurring on or after January 10, 2014. VA recognizes that the claimant establishing burial eligibility may be a different entity from the claimant
requesting reimbursement.
INSTRUCTIONS TO ESTABLISH BURIAL ELIGIBILITY: Type or print clearly all information. This form serves as a means for applicants to
certify information that is necessary to determine the decedent's eligibility for burial in a VA national cemetery. Applicants must: (1) complete and sign
this form then fax, email or mail the signed form and any military service discharge documents to the National Cemetery Scheduling Office (NCSO) at
1-866-900-6417 or [email protected], or PO Box 510543, St Louis, MO, 63151, and (2) follow-up with a phone call to NCSO at
1-800-535-1117 to determine eligibility for burial. PLEASE NOTE: VA determinations about a Veteran's burial eligibility are distinct from
determinations about entitlement to a claimed reimbursement. If you are also claiming reimbursement for a casket or urn, you must refer to Part II of this
form for instructions on how to submit a claim for reimbursement.
The eligibility criteria for burial in a VA national cemetery are stated in 38 U.S.C. §2402, Persons eligible for interment in national cemeteries. More
information about VA burial eligibility is available at the VA website online at: http://www.cem.va.gov/cem/bbene/eligible.asp, and in the latest edition
of the VA booklet: Federal Benefits for Veterans, Dependents and Survivors.
NAME OF DECEASED VETERAN

SOCIAL SECURITY NUMBER

SERVICE NUMBER

DATE OF DEATH

DID THE DECEDENT DIE IN A VA FACILITY?
YES (If YES, provide C-file number)

NO

DON'T KNOW

HAS THE DECEDENT BEEN OR WILL THE DECEDENT BE CREMATED?
YES (If YES, attach certificate of cremation)

NO

NAME OF FUNERAL HOME REPRESENTATIVE (If applicable)

ADDRESS

TELEPHONE NUMBER

By signing below I certify the following: I certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder
or other offense that could have resulted in imprisonment for life, has never been convicted of a serious crime, and has never been convicted of a sexual
offense for which he or she was sentenced to a minimum of life imprisonment. Definition for purposes of this section:
· The term “Federal capital crime” means an offense under Federal law for which a sentence of imprisonment for life or the death penalty may
be imposed.
· The term “State capital crime" means, under State law, the willful, deliberate, or premeditated unlawful killing of another human being for
which a sentence of imprisonment for life or the death penalty may be imposed. (Reference 38 U.S.C. 2411)
∙ The prohibition may apply if a person is found to have committed a Federal or State capital crime but was not convicted of such crime by
reason of such person not being available for trial due to death or flight to avoid prosecution.
SIGNATURE OF PERSON AUTHORIZED TO CERTIFY

DATE

PENALTY -The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false, or for the fraudulent acceptance of any benefit to which you are not entitled.
VA FORM
FEB 2014

40-10088

(Please complete Part II for Reimbursement, page 2)

PART II - INSTRUCTIONS FOR REQUESTING CASKET/URN REIMBURSEMENT

INSTRUCTIONS TO SUBMIT REQUEST FOR REIMBURSEMENT: Type or print clearly all information required. This form serves as a
means for applicants to certify information that is necessary to claim reimbursement for a casket or urn purchased for unclaimed deceased
Veterans with insufficient resources for burial. Applicants must: (1) complete and sign this form then fax, email or mail the signed form and any
military service discharge documents, along with the completed and signed ACH Vendor/Miscellaneous Payment Enrollment Form (SF 3881) to
the National Cemetery Scheduling Office (NCSO) at 1-866-900-6417 or [email protected], or PO Box 510543, St Louis, MO, 63151,
and (2) follow-up with a phone call to NCSO at 1-800-535-1117 to establish a case for reimbursement. VA will not provide reimbursement
unless the ACH Vendor/Miscellaneous Payment Enrollment Form (SF 3881) is submitted. NCSO will verify the applicant's certification that the
deceased Veteran has no NOK and insufficient resources for burial.
NAME OF FUNERAL HOME REPRESENTATIVE (If applicable)

ADDRESS

TELEPHONE NUMBER

NAME OF PURCHASER OF CASKET/URN

ADDRESS OF PURCHASER

PLEASE EXPLAIN IN DETAIL THE STEPS TAKEN TO DETERMINE THAT THE DECEASED VETERAN HAS NO NEXT OF KIN (NOK) AND NO SUFFICIENT
RESOURCES AVAILABLE FOR BURIAL.

PLEASE INCLUDE THE FOLLOWING ATTACHMENTS.
INVOICE/BILL OF SALE SHOWING MODEL NUMBER AND COST OF CASKET OR URN
ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM (SF 3881)

By signing below I certify the following:
I. The casket or urn purchased for burial meets industry standards for public health and safety. (The casket supports the weight of the body, is
not leaking, and has handles for lowering casketed remains into a gravesite; or the cremation urn is sealed and non-leaking.)
II. I certify, to the best of my knowledge, that I am requesting reimbursement of the purchase price of a casket or urn for the remains of a
deceased Veteran who is eligible for burial and who has no known next of kin and insufficient resources to purchase a burial receptacle.
SIGNATURE OF PERSON AUTHORIZED TO CERTIFY

DATE

PENALTY -The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false, or for the fraudulent acceptance of any benefit to which you are not entitled.

FOR COMPLETION BY VA NATIONAL CEMETERY OFFICIAL
BEFORE REIMBURSEMENT FOR THE CASKET OR URN CAN BE PROCESSED, ALL OF THE FOLLOWING STANDARDS OF QUALITY FOR BURIAL RECEPTABLE
AND DECEASED VETERAN'S IDENTITY MUST BE VERIFIED:
CASKET

ACCEPT (all items below are verified)

REJECT (if any item below is not verified)

EXTERIOR DIMENSIONS ARE GENERALLY 82 X 28 INCHES
CONSTRUCTED OF METAL
CONTAINS A GASKETED SEAL, AND IS NOT LEAKING
HAS FIXED RAILS OR SWING ARM HANDLES
HOLDS THE WEIGHT OF THE DECEDENT'S REMAINS
URN

ACCEPT

REJECT

CONSTRUCTED OF DURABLE PLASTIC
CERTIFICATE OF CREMATION FOR THE DECEDENT
SIGNATURE OF VA NATIONAL CEMETERY
ADMINISTRATION OFFICIAL

VA FORM 40-10088, FEB 2014, Page 2

DATE

ACKNOWLEDGMENT (SIGNATURE) OF FUNERAL
HOME/RESPONSIBLE ENTITY

DATE