Form 27-0820a Report of First Notice of Death

OMB Control No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

REPORT OF FIRST NOTICE OF DEATH
NOTE - This form must be filled out in ink or on a typewriter or 1. VA OFFICE
computer as it becomes a permanent record in the veteran's folder.

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY

EVENING

6B. E-MAIL ADDRESS (If applicable)
7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT (If applicable)

9. ADDRESS OF PERSON CONTACTED

10. TELEPHONE NUMBER OF PERSON CONTACTED

PERSONAL

TELEPHONE

(Include Area Code)

I certify that I properly identified my caller using the ID Protocol

11. FNOD INFORMATION

A. NAME OF DECEASED (First, middle, last)
B. CALLER'S RELATIONSHIP TO DECEASED
SURVIVING SPOUSE

OTHER (Explain)

SURVIVING CHILD

C. DATE OF DEATH (Month, day, year)
D. IF THE DECEASED IS THE VETERAN, DID HE/SHE DIE AT OR EN ROUTE TO A VA OR CONTRACTED MEDICAL FACILITY/NURSING HOME?
YES

(If, "Yes," provide name, city and state)

NO

E. NAME OF VETERAN'S SURVIVING DEPENDENT(S) (If any)

F. SURVIVING DEPENDENT(S) ADDRESS & PHONE NUMBER (If needed)

12. DEATH OF VETERAN - FNOD ACTION
I CERTIFY THAT I ADVISED THE CALLER THE BENEFITS WILL BE STOPPED THE FIRST OF THE MONTH OF DEATH (If applicable)
I CERTIFY I LOOKED UP VETERAN'S RECORD (BINQ, VID, M11, or corporate equivalents)
I CERTIFY I ANSWERED QUESTIONS CONCERNING POSSIBLE BENEFIT ENTITLEMENTS REFERRING TO "DEATH RELATED INFORMATION CHECKLIST"
WORK AID
I CERTIFY I PROCESSED THE VETERAN'S FNOD IN SHARE
YES

NO (If, "No," explain)

I CERTIFY I SENT THE FOLLOWING:
PMC

NOK LETTER

Claims file location in BIRLS:

21-530

21-534

40-1330 and/or

OTHER (Please specify)

13. DEATH OF A NON-VETERAN BENEFICIARY - FOR STOP PAYMENT ACTION

I CERTIFY I ADVISED THE CALLER THE BENEFITS WILL BE STOPPED THE FIRST OF THE MONTH OF DEATH AND THAT ANY PAYMENT ISSUED FOLLOWING
THAT DATE MUST BE RETURNED
I CERTIFY I ADVISED THE CALLER OF POSSIBLE BURIAL OF SPOUSE/CHILD IN A NATIONAL CEMETERY
I CERTIFY THAT I WILL ROUTE THIS REPORT OF DEATH TO REGIONAL OFFICE OF JURISDICTION OR PMC VIA ENCRYPTED E-MAIL FOR STOP PAYMENT
PROCESSING

14. FOR ALL CALLS
I certify that I read the following statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA benefits. The primary
purpose for gathering this information or statement is to make an eligibility determination. It is subject to verification through computer matching programs with
other agencies."
cc: POA (If applicable)
DIVISION OR SECTION

EXECUTED BY (Signature and title)

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA/21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to obtain evidence in support of your claim for benefits (38 U.S.C. 501(a) and (b)). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 5 minutes to respond to the questions on this form. VA cannot conduct or sponsor a collection of information unless a valid OMB
control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
VA FORM
XXX 20XX

27-0820a

SUPERSEDES VA FORM, 27-0820a, APR 2013,
WHICH WILL NOT BE USED.