Va 40-1330m

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.
PRIVACY ACT - 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, 48VA40B, published in the Federal Register. VA considers the
requested information relevant and necessary to determine maximum benefits under the law.
BENEFIT PROVIDED - MEDALLION (Only for eligible deceased Veterans who served in the Armed Forces on or after April 6, 1917, regardless of their date
of death)
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 or local Government cemetery. The medallion is made of bronze and available in three sizes: Large, Medium, Small. Each medallion is inscribed
with the word VETERAN across the top and the Branch of Service at the bottom (see Note in Block 11 of the claim for further information). An eligible deceased
Veteran 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, Claim for Standard Government Headstone or Marker.

Shown below are the three medallions with the actual dimensions (+/- 1/32") for width and height.

Large Medallion
Dimensions: 6 3/8" W, 4 3/4" H, 1/2" D

Medium Medallion
Dimensions: 3 3/4" W, 2 7/8" H, 1/4" D

Small Medallion
Dimensions: 2" W, 1 1/2" H, 1/3" 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 served in the Armed Forces on or after April 6, 1917,
and is buried in a private cemetery in a grave marked with a privately purchased headstone or marker. Please attach 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. If you are unable to locate copies of military
records, apply anyway, as VA will attempt to obtain records necessary to make an eligibility determination. 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; please submit a copy of the Reserve Retirement Eligibility Benefits Letter with 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 - An "applicant" for a Medallion may be any of the following:
(i)

A decedent's family member, which includes the decedent's spouse or individual who was in a legal union as defined in 38 CFR 3.1702(b)(1)(ii) with the
decedent; a child, parent, or sibling of the decedent, whether biological, adopted, or step relation; and any lineal or collateral descendant of the decedent;
(ii) A personal representative, defined as a family member or other individual who has identified himself or herself as the person responsible for making
decisions concerning the interment of the remains of or memorialization of a deceased individual;
(iii) A representative of a Congressionally-chartered Veterans Service Organization;
(iv) An individual employed by the relevant state, tribal organization, or local government whose official responsibilities include serving veterans and families
of veterans, such as a state or county veterans service officer; or
(v) Any individual who is responsible, under the laws of the relevant state or locality, for the disposition of the unclaimed remains of the decedent or for other
matters relating to the interment or memorialization of the decedent.
PRESIDENTIAL MEMORIAL CERTIFICATE - A Presidential Memorial Certificate (PMC) is an engraved paper certificate, signed by the current sitting
president, to honor the memory of Veterans discharged under other than dishonorable conditions. If the Veteran is eligible for a headstone, marker, or medallion, one
PMC will automatically be provided unless otherwise specified. Additional PMCs may be requested by indicating how many in block 18 of this form.
HOW TO SUBMIT A CLAIM
FAX VA Form 40-1330M 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 Products 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 claimant signs in block 19; the cemetery or other responsible official in block 24. If there is no official on duty at the cemetery,
the signature of the person responsible for the property listed in block 23 is required. Entries of "None," "Not Applicable," or "NA" will not be accepted.
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]. If additional assistance is needed to complete this claim, contact the nearest VA Regional Office, national cemetery, or a local Veterans'
organization. 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 21 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 or local Government cemetery.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
OCT 2017

40-1330M

ALL PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE

Department of Veterans Affairs
National Cemetery Administration
Memorial Products Service
To: MEMORIAL PRODUCTS SERVICE (41B)
Fax Number: 1-800-455-7143
From:
Sender's Phone Number:
Sender's Fax Number:
Total No. of Pages (including cover sheet):

This optional fax cover sheet is provided for your convenience. This fax number is dedicated to the transmission of claims for
headstones, markers, and medallions. If you prefer, you may mail your claim and supporting documents to the address below:
Memorial Products Service (41B)
Department of Veterans Affairs
5109 Russell Road
Quantico, VA 22134-3903
The 1-800-455-7143 fax line only accepts claims for Government Headstones, Markers, Medallions and
Presidential Memorial Certificates; it cannot accept any other claims for Government Benefits.
Include all supporting documents with this medallion claim (i.e., DD Form 214 or equivalent discharge
document).
IMPORTANT: If you are requesting a replacement medallion due to an incorrect size, damage, or non-reciept,
please explain:

.

To submit multiple claims packages: Fax one claim package (claim plus supporting documents) at a time. You
must disconnect the call and redial between each claim package. Faxing several claims without redialing between
each one will delay the processing of your claims.

Form approved, OMB No. 2900-0222
Expiration Date: Feb. 18, 2017
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. Failure to complete each block may result in delayed processing. PLEASE INCLUDE
MILITARY DISCHARGE DOCUMENTS.
2. NAME OF DECEASED VETERAN
MIDDLE (Or Initial)
LAST

FIRST (Or Initial)

SUFFIX

4. RACE OR ETHNICITY (You may select more than one. Information will be used for statistical purposes only.)
AMERICAN INDIAN OR ALASKA NATIVE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

1. DID VA PREVIOUSLY DETERMINE ELIGIBILITY FOR
BURIAL AT A VA NATIONAL CEMETERY?
YES

NO

UNSURE

3. THERE MUST BE A SET HEADSTONE,
MAUSOLEUM, OR CRYPT IN PLACE TO AFFIX
THE MEDALLION. IS THE GRAVE CURRENTLY
MARKED?
YES
NO
5. GENDER (Information will be used 6. AGE AT TIME
for statistical purposes only.)
OF DEATH

BLACK OR AFRICAN AMERICAN

WHITE

MALE

HISPANIC OR LATINO

OTHER (Specify)

FEMALE

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
8. PLACE OF BIRTH (City and State or Country)

7. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO.
SSN:

SVC. NO.:

9A. DATE OF BIRTH
MONTH
DAY
YEAR

9B. DATE OF DEATH
MONTH
DAY
YEAR

PERIODS OF ACTIVE MILITARY DUTY

10A. DATE(S) ENTERED
MONTH
DAY
YEAR

10B. DATE(S) SEPARATED
MONTH
DAY
YEAR

11. 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)
12. MEDALLION SIZE REQUESTED (Check one) (Refer to general information sheet for exact sizes)
LARGE (M5)

MEDIUM (M3)

SMALL (M1)

13. ARE YOU:
FAMILY MEMBER (Specify relationship)

VETERANS SERVICE OFFICER

PERSONAL REPRESENTATIVE (Person responsible for
decisions concerning burial or memorialization of decedent)
14. NAME AND MAILING ADDRESS OF CLAIMANT
(No., Street, City, State, and ZIP Code)

FUNERAL HOME MANAGEMENT
(that received remains)
15. DAYTIME PHONE NO.
16. E-MAIL ADDRESS (Optional)
OF CLAIMANT

18. IF "YES" HOW MANY?

17. I WOULD LIKE A PRESIDENTIAL MEMORIAL CERTIFICATE?
YES

CEMETERY MANAGEMENT
(where remains are buried)

NO

CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in Block
21 at no expense to the Government, and that I (or the party listed in Block 19) 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.
20. DATE (MM/DD/YYYY)

19. SIGNATURE OF CLAIMANT

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

22. DAYTIME PHONE NO.
(Include Area Code)

23. NAME AND ADDRESS OF CEMETERY WHERE PRIVATELY PURCHASED
HEADSTONE IS IN PLACE OR A MAUSOLEUM, OR CRYPT TO AFFIX
THE MEDALLION MARKER OF THE DECEASED VETERAN IS LOCATED
(No., Street, City, State, and ZIP Code)

CERTIFICATION: By signing below I certify the size medallion indicated above is permitted in the cemetery.
24. SIGNATURE OF CEMETERY OFFICIAL

VA FORM
OCT 2017

40-1330M

25. DATE (MM/DD/YYYY)

ALL PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE