Form 40-10007 Preneed Burial Planning

OMB NUMBER: 2900-0784
EXPIRATION DATE:
RESPONDENT BURDEN: 15 minutes

APPLICATION FOR PRE-NEED DETERMINATION OF
ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY

Submit Application and Supporting Documentation to VA by:
Email: to the National Cemetery Scheduling Office at [email protected]; or
Mail: to National Cemetery Scheduling Office, P.O. Box 510543, St. Louis, MO 63151; or
Fax: to the National Cemetery Scheduling Office at (855) 840-8299

NOTE: Please read information on reverse before
completing this form. If additional space is required,
attach a separate sheet of paper.

IMPORTANT: Pre-Need means before death. Only complete this form if you are applying for a Pre-Need determination of eligibility for burial in a VA national
cemetery. Time of Need means time of death. DO NOT complete this form if the individual is deceased; instead, contact a local funeral home or the National Cemetery
Scheduling Office at 1-800-535-1117 to apply for expedited processing.
*REQUIRED ITEMS: YOU MUST COMPLETE THOSE ITEMS IDENTIFIED WITH AN ASTERISK (*)
SECTION I - VETERAN/SERVICEMEMBER INFORMATION
(Claims for eligibility for burial are based upon the Veteran's/Servicemember's military service)
*1. VETERAN/SERVICEMEMBER NAME (Include
*2. NAME USED DURING MILITARY SERVICE (If different than
3. MAILING ADDRESS
Suffix) (Last, First, Middle Name)
Item 1) (Last, First, Middle Name) (Include Suffix)
(Street, City, State, and Zip Code)

4. SOCIAL SECURITY NUMBER 5. MILITARY SERVICE NUMBER (If different from SSN)

6. VA CLAIM NUMBER (If known)

*7. GENDER
MALE

FEMALE

*10. IS VETERAN/SERVICEMEMBER DECEASED? 11. DATE OF DEATH (If applicable) (MM/DD/YYYY)

*8. DATE OF BIRTH (MM/DD/YYYY) 9. PLACE OF BIRTH

YES

NO

DON'T KNOW

*12. MARITAL STATUS
*13. MILITARY STATUS USED TO APPLY FOR ELIGIBILITY DETERMINATION
SINGLE
SEPARATED
A. VETERAN
B. RETIRED ACTIVE DUTY
C. DIED ON ACTIVE DUTY
D. RETIRED RESERVE OR NATIONAL GUARD
MARRIED
DIVORCED
F. OTHER (See instructions)
E. DEATH RELATED TO INACTIVE DUTY TRAINING
WIDOWED
MILITARY DATA
*14. BRANCH OF SERVICE

15. DATE OF ENTRY 16. DATE OF
DISCHARGE

20. IS ANYONE BURIED IN A VA NATIONAL CEMETERY UNDER
THIS VETERAN'S/SERVICEMEMBER'S ELIGIBILITY?
NO (Skip Item 21)
YES (Complete Item 21)
DON'T KNOW (Skip Item 21)
22. SUPPORTING DOCUMENTS ATTACHED

17. DISCHARGE - CHARACTER 18. HIGHEST RANK ATTAINED 19. STATE (Abbrev.)
(National Guard Only)
(No pay grades)
OF SERVICE (See instructions)

21. NAME OF DECEDENT(S) AND THE VA NATIONAL CEMETERY WHERE BURIED

NO (See instructions for information on recommended documentation.)

YES

SECTION II - CLAIMANT INFORMATION
(Information about the individual for whom the determination of eligibility for burial in a VA National Cemetery is requested)
*24. MAILING ADDRESS OF CLAIMANT (Street, City, State, and Zip Code)
*23. CLAIMANT (See instructions)
(If different from item 3)

(Name) Last

First

Middle

*25. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

WHO IS (check only one):

26. CLAIMANT'S SOCIAL SECURITY NUMBER (If different from item 4)

A. THE VETERAN/SERVICEMEMBER NAMED IN ITEM 1
B. THE SPOUSE/SURVIVING SPOUSE OF THE VETERAN/SERVICEMEMBER
C. AN UNMARRIED ADULT CHILD OF THE VETERAN/SERVICEMEMBER

*27. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY ) (If different from item 8)
*28. CLAIMANT'S MAIDEN NAME (If applicable)

IMPORTANT: A separate VA Form 40-10007 must be completed for each Claimant.
29. DESIRED VA NATIONAL CEMETERY (Optional - See instructions)

30. EMAIL ADDRESS (Optional - See instructions)

SECTION III - CERTIFICATION AND SIGNATURE

CERTIFICATION: By signing below, I certify that I am the Claimant or Claimant's authorized agent or representative, and that all information entered on this form is
true and correct to the best of my knowledge. A fraudulent statement that leads to burial in a VA national cemetery or receiving other benefits from the VA could result
in disinterment from that VA national cemetery and other penalties in accordance with the law. I acknowledge that otherwise eligible individuals may be barred from
burial for committing certain serious crimes. VA will therefore validate a previous determination of eligibility at the time of a burial request to check for those bars in
addition to law changes or Claimant status changes that may affect eligibility of the Claimant.
*31. YOUR SIGNATURE

*32. DATE

*33. YOUR RELATIONSHIP TO THE CLAIMANT IN ITEM 23 (See instructions)
AUTHORIZED AGENT OR REPRESENTATIVE
SELF (Stop-form complete)
OF THE CLAIMANT (Complete items 34 through 38)

*34. NAME OF AUTHORIZED AGENT OR REPRESENTATIVE
35. REASON YOU ARE COMPLETING THIS FORM FOR THE CLAIMANT (See instructions)
COMPLETING THIS FORM FOR THE CLAIMANT (Last, First, Middle Name)
*36. MAILING ADDRESS OF INDIVIDUAL COMPLETING THIS FORM
FOR THE CLAIMANT (Street, City, State, and Zip Code)

VA FORM
DEC 2015

40-10007

37. TELEPHONE NUMBER
(Include Area Code)

38. EMAIL ADDRESS (Optional)

INSTRUCTIONS FOR COMPLETING VA FORM 40-10007 APPLICATION FOR PRE-NEED ETERMINATION OF
ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY
For more complete information on eligibility requirements for burial in a VA national cemetery, visit the National Cemetery Administration
online at http://www.cem.va.gov/cem/burial_benefits/eligible.asp or call the National Cemetery Scheduling Office at 1-800-535-1117. For
the purposes of this form, the term burial includes inurnment (above ground remains placement in a columbarium) and scattering of ashes, (if
the cemetery chosen offers those options). A Pre-Need determination of eligibility does not guarantee burial in a specific VA national
cemetery. Burial in a specific VA national cemetery will be scheduled at the Time of Need. In order to assist in completing this form,
specific instructions and explanations for certain items are given below.
SECTION I: VETERAN/SERVICEMEMBER
Eligibility for burial in a VA national cemetery is based on the qualifying service of a Veteran/Servicemember. This section of the form is
used to determine if qualifying service exists.
Item 13 Military status used to apply for eligibility determination: For VA benefit purposes, a Veteran is a person who served in the
active military, naval, or air service, and who was discharged under conditions other than dishonorable. VA will determine on a
case-by-case basis certain Reserve duty that confers qualifying status. If eligibility derives from a status not listed, or if the
individual is not certain of the status, check “Other” and submit evidence of service and VA will provide appropriate assistance. VA
will not provide pre-need determinations for Active Duty Servicemembers unless they have a record of prior qualifying service.
However, Servicemembers who die on active duty are eligible for burial. If you are arranging burial of a Servicemember or his/her
dependent spouse or adult unmarried child, you should contact a local funeral home or the National Cemetery Scheduling Office at
1-800-535-1117 to apply for expedited processing.
Item 17 Discharge - Character of Service: Please indicate one type of “Discharge - Character of Service”: Honorable; General; Entry
Level Separation/Uncharacterized; Other Than Honorable; Bad Conduct; or Dishonorable. If uncertain of the type of discharge or
character of service, indicate “Other” and include available supporting documents.
Item 22 Supporting military service documents: VA recommends that you attach photocopies of readily available supporting documents
so that we can make the determination quickly. Those documents may include the most recent discharge document (DD Form 214)
showing the highest rank and valor awards and decorations, active duty service records other than for training purposes, or active
duty of more than 24 months of continuous service (for enlisted Servicemembers after September 7, 1980; for officers, after
October 16, 1981). However, if you are unable to locate copies of military records, apply anyway, as VA will attempt to obtain
records necessary to make a determination.
SECTION II: CLAIMANT INFORMATION
Item 23 Each Claimant requires a separate VA Form 40-10007.
23b. Spouse/Surviving Spouse means a person who is or was legally married to a Veteran and for the purpose of burial in a VA
national cemetery a surviving spouse includes a surviving spouse who had a subsequent remarriage.
23c. An unmarried adult child of the Veteran is an individual who became permanently physically or mentally disabled and
incapable of self-support before reaching 21 years of age, or before reaching 23 years of age if pursuing a full-time course of
instruction at an approved educational institution. If you are making a claim for an unmarried adult child, please provide supporting
documentation such as recent medical documentation pertaining to the disability, date of onset of the disability, and the age of the
Claimant when diagnosed with this disability. VA recommends that you provide photocopies.

Items
29 and
30

Note: Minor children of eligible Veterans are eligible for burial in VA national cemetery. VA will not issue a Pre-Need
determination of eligibility letter for minor children. The minor child of an eligible Veteran is a child who is unmarried and who is
under 21 years of age; or who is under 23 years of age and is pursuing a full-time course of instruction at an approved educational
institution.
You will find a list of VA national cemeteries online at http://www.cem.va.gov/cem/cems/allnational.asp A Pre-Need
determination of eligibility does not guarantee burial in a specific VA national cemetery. Burial in a specific VA national
cemetery will be scheduled at the time of need. If you provide an email address, VA may use your email address to communicate
with you about your claim and burial benefits.
SECTION III: CERTIFICATION AND SIGNATURE

Item 31 You must sign and date this application in order for VA to process. VA prefers that each Claimant sign his/her own
application, however we will accept Pre-Need applications from the Claimant's authorized agent or representative.
Item 33 Your Relationship To The Claimant. Self means you are the Claimant. An Authorized Agent or Representative of the Claimant
is the individual or organization who is authorized to make decisions on his or her behalf. Written authorization should be included
with the form if available. A notarized statement is not required.
Item 35 Explain why the Claimant is not available or able to sign this form.
Privacy Act Information: VA considers the responses you submit confidential (38 U.S.C. 5701). VA may only disclose this information
outside the VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records,
42VA41, published in the Federal Register. VA considers the requested information relevant and necessary to determine maximum benefits
under the law.
Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
the time to review instructions, search existing data sources, gather the necessary data, and complete and review the collection of information.
The obligation to respond is voluntary and not required to obtain or retain benefits.

REVERSE OF VA FORM 40-10007, DEC 2015