VA 40-1330M Claim For Government Medallion For Placement in a Privat

GENERAL INFORMATION SHEET
CLAIM FOR GOVERNMENT MEDALLION FOR PLACEMENT
IN A PRIVATE CEMETERY
RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. VA cannot conduct or sponsor a collection of information unless it has a valid OMB number. Your obligation to respond is voluntary,
however, your response is required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to the VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. Please DO
NOT send applications for benefits to this address.
BENEFIT PROVIDED - MEDALLION (Only for Veterans who died on or after November 1, 1990)
Furnished upon receipt of claim for affixing to an existing privately-purchased headstone or marker placed at the gravesite of an eligible deceased Veteran
who is buried in a private cemetery. The medallion is made of bronze and available in three approximate sizes: 5 inches, 3 inches, and 1-1/2 inches. Each
medallion is inscribed with the word VETERAN across the top and the Branch of Service at the bottom (see Note in Block 6 of the claim for further
information). Eligible Veterans may receive a Government furnished headstone or marker, or a medallion, but not both. If requesting a headstone or
marker, please use the VA Form 40-1330.
Shown below are the three medallions with the maximum dimensions for height and length.

Five inch Medallion
Dimensions: 6 1/2" W, 4 3/4" H, 1/2" D

Three inch Medallion
Dimensions: 3 3/4" W, 2 3/4" H, 1/4" D

One-and-one-half inch Medallion
Dimensions: 2" W, 1 1/2" H, 1/4" D

WHO IS ELIGIBLE - Any member of the Armed Forces of the United States who dies on active duty and is buried in a private cemetery in a grave
marked with a privately purchased headstone or marker. Any deceased Veteran discharged under honorable conditions, who died on or after November 1,
1990, and is buried in a private cemetery in a grave marked with a privately purchased headstone or marker. A deceased Veteran discharged under
conditions other than honorable, who died on or after November 1, 1990, and is buried in a private cemetery in a grave marked with a privately purchased
headstone or marker, may also be eligible. A copy of the deceased Veteran's discharge certificate (DD Form 214 or equivalent) or a copy of other official
document(s) establishing qualifying military service must be attached. Do not send original documents; they will not be returned. Service after
September 7, 1980, must be for a minimum of 24 months continuous active duty or be completed under special circumstances, e.g., death on active
duty. Persons who have only limited active duty service for training while in the National Guard or Reserves are not eligible unless there are special
circumstances, e.g., death while on active duty, or as a result of training. Reservists and National Guard members who, at time of death, were entitled to
retired pay, or would have been entitled, but for being under the age of 60, are eligible; a copy of the Reserve Retirement Eligibility Benefits Letter must
accompany the claim. Reservists called to active duty other than training and National Guard members who are Federalized and who serve for the period
called are eligible.
WHO CAN APPLY - Federal regulation defines "applicant" as the decedent's Next of Kin (NOK); a person authorized in writing by the NOK; or a
personal representative authorized in writing by the decedent. Written authorization must be included with claim. A notarized statement is not required.
HOW TO SUBMIT A CLAIM
FAX claims and supporting documents to: 1-800-455-7143.
IMPORTANT: If faxing more than one claim - fax each
claim package (claim plus supporting documents) individually
(disconnect the call and redial for each submission).

MAIL claims to: Memorial Programs Service (41B)
Department of Veterans Affairs
5109 Russell Road
Quantico, VA 22134-3903

A VA medallion may be furnished only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED - The applicant must sign in Block 12A. The applicant must be the Next of Kin or an authorized representative of the
decedent or the Next of Kin.
ASSISTANCE NEEDED - If assistance is needed to complete this claim, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or
via e-mail at [email protected]. No fee should be paid in connection with the preparation of this claim. For more information regarding medallion
eligibility, affixing procedures, and sizes, visit our website at www.cem.va.gov.
DELIVERY - The medallion is shipped without charge to the name/address designated in Block 13 of the claim. The Government is not responsible for
costs associated with affixing the medallion to the privately purchased headstone or marker. Appropriate affixing adhesives, hardware and instructions are
provided with the medallion.
CAUTION - To avoid delays in the production and delivery of the medallion, please check carefully to be sure you have accurately furnished all required
information and documents before faxing or mailing the claim. The Government is not responsible for costs associated with affixing the medallion to the
privately purchased headstone or marker. Medallions furnished remain the property of the United States Government and may not be used for any purpose
other than to be affixed to the privately purchased headstone or marker of an eligible deceased Veteran buried in a private cemetery.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
SEP 2013

40-1330M

ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE 60 DAYS FOLLOWING THE DATE OF THIS FORM.

Form approved, OMB No. 2900-0222
Expiration Date: Xxx, 20XX
Respondent Burden: 15 minutes

CLAIM FOR GOVERNMENT MEDALLION FOR
PLACEMENT IN A PRIVATE CEMETERY
IMPORTANT: Please read the General Information Sheet before completing this claim. Type or print clearly all information except for signatures.
Illegible printing could result in incorrect delivery of the medallion. Unless indicated otherwise all other blocks must be completed. MILITARY
DISCHARGE DOCUMENTS OR RELATED SERVICE INFORMATION ARE REQUIRED.
2. GRAVE IS:

1. NAME OF DECEASED VETERAN
FIRST (Or Initial)

MIDDLE (Or Initial)

LAST

CURRENTLY MARKED
(with privately purchased marker)

SUFFIX

NOT MARKED

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
PERIODS OF ACTIVE MILITARY DUTY

3. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO.

5A. DATE(S) ENTERED
SSN:

SVC. NO.:

4A. DATE OF BIRTH
MONTH

DAY

DAY

MONTH

5B. DATE(S) SEPARATED
YEAR

MONTH

DAY

YEAR

4B. DATE OF DEATH
YEAR

MONTH

DAY

YEAR

6. BRANCH OF SERVICE (BOS) (Check applicable box(es)) NOTE: If one BOS is selected, it will be spelled out on the medallion, i.e. U.S. ARMY,
U.S. AIR FORCE, etc. If more than one BOS is selected, they will be abbreviated on the medallion, i.e. USA, USAF, USN, USMC, USCG, etc.
ARMY

MARINE CORPS

COAST GUARD

MERCHANT MARINE

NAVY

AIR FORCE

ARMY AIR FORCES (WW II)

OTHER (USAAC,
WAAC, etc.) (Specify)

8. NAME AND MAILING ADDRESS OF APPLICANT
(No., Street, City, State, and ZIP Code)

7. MEDALLION SIZE REQUESTED
(Check one) (Refer to instructions
for exact sizes)
5 INCH (M5)
3 INCH (M3)
1-1/2 INCH (M1)

10. DAYTIME PHONE NO. OF APPLICANT

9. ARE YOU:
NEXT OF KIN
(Specify Relationship)

AUTHORIZED REPRESENTATIVE ON BEHALF OF
DECEDENT (Include Written Authorization)

11. E-MAIL ADDRESS (Optional)

AUTHORIZED REPRESENTATIVE ON BEHALF OF
NEXT OF KIN (Include Written Authorization)

CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in Block
15 at no expense to the Government, and that I (or the party listed in Block 13) have agreed to accept delivery, and all information entered on this claim is
true and correct to the best of my knowledge. I also 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.
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.
12B. DATE (MM/DD/YYYY)

12A. SIGNATURE OF APPLICANT

13. NAME AND DELIVERY ADDRESS FOR MEDALLION
(No., Street, City, State, and ZIP Code); (If same as
applicant, please enter SAME)

VA FORM
SEP 2013

40-1330M

14. DAYTIME PHONE NO.
(Include Area Code)

15. NAME AND ADDRESS OF CEMETERY WHERE PRIVATELY
PURCHASED HEADSTONE OR MARKER OF THE DECEASED VETERAN
IS LOCATED (No., Street, City, State, and ZIP Code)

ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE 60 DAYS FOLLOWING THE DATE OF THIS FORM.