Application for Pre-Need Determination_40-10007 edits

12/023/15 117:300 PAM

OMB NUMBER: 2900-0784 EXPIRATION DATE: RESPONDENT BURDEN: 15 minutes APPLICATION FOR PRE-NEED DETERMINATION OF ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY

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

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

IMPORTANT: Pre-Need means before death. Only complete this form if you are applying for Pre-Need dDetermination of eligibility for burial in a VA national cemetery. Time of Need means time of deathhe individual is deceased. DO NOT complete this form if the individual is already 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 (Claims for eligibility for burial are based upon the Veteran/Servicemember’s military service)

*1. VETERAN/SERVICEMEMBER NAME (Include Suffix) (Last, First, Middle Name or Initial)

*2. NAME USED DURING MILITARY SERVICE (Include Suffix) (If different than Item 1) (Last, First, Middle Name)

3. VETERAN’S MAILING ADDRESS (Street Address, City, State, and Zip Code, P.O. Box, Rural Route, etc.)

4. SOCIAL SECURITY NUMBER

5. MILITARY SERVICE NUMBER (If different from Social Security Number)

6. VA CLAIM NUMBER (If known)

*7. GENDER ☐MALE ☐FEMALE

8. DATE OF BIRTH (MM/DD/YYYY)

9. PLACE OF BIRTH

*10. IS VETERAN/SERVICEMEMBER DECEASED? ☐ YES ☐ NO ☐DON’T KNOW

11. DATE OF DEATH (If applicable) (MM/DD/YYYY)

*12. MARITAL STATUS ☐ Single ☐ Separated ☐ Married ☐Divorced ☐ Widowed

*13. MILITARY STATUS USED TO APPLY FOR ELIGIBILITY DETERMINATION ☐ A. Veteran ☐ B. Retired Active Duty ☐ C. Died on Active Duty ☐ D. Retired Reserve or National Guard ☐ E. Death Related to Inactive Duty Training ☐F. Other (See instructions)

MILITARY SERVICE DATA

*14. BRANCH OF SERVICE

15. DATE OF ENTRY

16. DATE OF DISCHARGE

17. DISCHARGE - CHARACTER OF SERVICE (See Instructions)

18. HIGHEST RANK ATTAINED (No pay grades)

19. STATE (Abbrev.) (For National Guard Service Only)

20. IS THERE ANYONE CURRENTLY BURIED IN A VA NATIONAL CEMETERY UNDER THIS VETERAN'S/SERVICEMEMBER'S ELIGIBILITY? ☐YES (If Yes, complete Item 21) ☐ NO (Skip Item 21) ☐ DON'T KNOW (Skip Item 21)

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

22. SUPPORTING DOCUMENTS ATTACHED ☐☐ YES ☐ NO (See instructions for information on recommended documentation)

SECTION II - CLAIMANT INFORMATION - (Information about the individual for whom determination for eligibility for burial in a VA national cemetery is requested)The individual for whom future burial in a National Cemetery is desired

*23. THIS CLAIM IS MADE FOR FUTURE DESIRED BURIAL OF CLAIMANT (See instructions) __ _______________________________________________________ (Name) Last First Middle WHO IS (check one): ☐ A. the Veteran/Servicemember named in Item 1 ☐ B. the Spouse/Surviving Spouse of Veteran/Servicemember ☐ C. an Unmarried Adult Child of the Veteran/Servicemember ***Each Claimant Rrequires a separate VA Form 40-10007***

*24. CLAIMANT’S MAILING ADDRESS (Street Address, City, State, and Zip Code, P.O. Box, Rural Route, etc.) (if different from item 3)

25. CLAIMANT’S TELEPHONE NUMBER (Include Area Code)

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

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

*28. CLAIMANT'S MAIDEN NAME (If applicable)

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 national cemetery or receiving other benefits from the VA could result in disinterment from that 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.By signing below, I certify that I am the Claimant orClaimant’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 national cemetery or receiving other benefits from the VA could result in disinterment from that 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. I also acknowledge that VA may use the information on this form, at any time, to investigate if a bar to burial may exist.

*31. YOUR SIGNATURE

32. Date

*33. YOUR RELATIONSHIP TO THE CLAIMANT IN ITEM 23 (See instructions) ☐Self (Stop-form complete) ☐ Authorized Agent or Representative of the Claimant (Complete items 34 through 38)

*34. NAME OF AUTHORIZED AGENT OR REPRESENTATIVE COMPLETING FOR THE CLAIMANT (Last, First, Middle Name)

35. REASON YOU ARE COMPLETING FOR THE CLAIMANT (See instructions)

*36. MAILING ADDRESS OF INDIVIDUAL COMPLETING FOR THE CLAIMANT (Street Address, City, State, and Zip Code, P.O. Box, Rural Route, etc.)

*37. TELEPHONE NUMBER (Include Area Code)

38. EMAIL ADDRESS (Optional)

_{VA FORM}

_{DEC 2015} 40-10007

INSTRUCTIONS FOR COMPLETING VA FORM 40-10007 APPLICATION FOR PRE-NEED DETERMINATION OF ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY
For more complete information on eligibility requirements for burial in a VA nNational Ccemetery, 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 national cemetery. Burial in a specific 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 Sstatus used to aApply for Eeligibility Ddetermination: 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 Servicemembers or their 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 an expedited processing.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 or her spouse or 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 Discharge; or Dishonorable. If uncertain of the type of discharge or character of service, indicate “Other” and include available supporting documents.
Item 22	Supporting Mmilitary sService dDocuments: 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, I 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. f 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. Spouse/Surviving Spouse means a person who is or was the legally married spouse of a Veteran and who lived with the Veteran continuously from the date of marriage to the date of the Veteran's death (except where there was a separation which was due to the misconduct of, or procured by, the Veteran without the fault of the spouse) and who has not remarried or (in cases not involving remarriage) has not since the death of the Veteran, and after September 19, 1962, lived with another person and held himself or herself out openly to the public to be the spouse of such other person. 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 a 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. 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.
Items 29 and 30	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 national cemetery. Burial in a specific VA national cemetery will be scheduled at the Time time of Nneed. If you provide an e-mail address, VA may use your email address to communicate with you about your claim and burial benefits. in general
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. 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. Information submitted is subject to verification through computer matching programs with other agencies. 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

REVERSE OF VA FORM 40-10007, OCT 2015