Form 21P-530EZ Application for Burial Benefits

NOTICE OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM
FOR BURIAL BENEFITS (UNDER 38 U.S.C., CHAPTER 23)
This notice provides information regarding the evidence necessary to substantiate a claim for:
Non-service-connected Burial Allowance
Service-connected Burial Allowance
VA Hospitalization Death Burial Allowance
Plot or Interment Allowance
Transportation Reimbursement
Unclaimed Remains of Veteran
When to Use this Form
Use this notice and the attached application to submit a claim for any of the above named burial allowances and related burial benefits.
This notice informs you of the evidence necessary to decide your claim. After you submit your claim on the attached application, you
will not receive an initial letter regarding your claim. You do not need to submit another application.
If you are filing a claim for new burial benefits or disagree
with an evaluation decided more than one year ago...
If you disagree with a burial decided within the past year
and have new and relevant evidence OR
If you are filing a supplemental claim (a claim after an
initial claim for the same burial benefit(s) previously
decided)...

Please complete and submit VA Form 21P-530EZ,
Application for Burial Benefits

Please complete and submit VA Form 20-0995, Decision
Review Request: Supplement Claim**

**You may also file a request for a higher-level review or an appeal to the Board of Veterans' Appeals. For additional information on
all these different options, please visit https://benefits.va.gov/benefits/appeals.asp.
Want to apply electronically? You can apply for VA burial benefits online at https://www.va.gov/. You can also upload all
supporting evidence you may have and make your claim a Fully Developed Claim (FDC).
NOTE: You may wish to contact an accredited Veterans Service Officer (VSO) to assist you with your application. For a list of
accredited Veterans Service Organizations go to https://www.va.gov/vso/. You may also contact your state office of Veterans Affairs
at https://www.va.gov/statedva.htm should you need further assistance with the application process.
Want your claim processed faster? The FDC Program is the fastest way to get your claim processed without any risk to participate!
To participate, submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for survivor
benefits, use VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits. VA forms are available at
www.va.gov/vaforms.
NOTE: Participation in the FDC program is optional and will not affect the benefits to which you are entitled. If you file a claim in
the FDC Program and it is determined that other records exist and VA needs the records to decide your claim, then VA will simply
remove the claim from the FDC Program and process it in the Standard Claim Process. If you wish to file your claim in the FDC
Program, see FDC Program (Optional Expedited Process) on page 3. If you wish to file your claim under the process in which VA
traditionally processes claims, see Standard Claim Process on page 3.
FEES for claims: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains
provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in
connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered
by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a
claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the
applicable power-of-attorney and the fee agreement requirements.
GENERAL INFORMATION
1. ELIGIBLE CLAIMANTS (Who Should File A Claim):
Check the appropriate box on the form (block 10) regarding your relationship to the veteran to certify your correct claimant
eligibility.
VA may grant a claim that any eligible person files. Upon death of the veteran, VA will pay the first living person to file a claim
of those listed below:
• The veteran's surviving spouse; OR
• The survivor of a legal union between the deceased veteran and the survivor; OR
• The veteran's children, regardless of age (biological, step and adopted); OR
• The veteran's parents or the surviving parent; OR
VA FORM
XXXX

21P-530EZ

SUPERSEDES VA FORM 21P-530, APR 2017,
WHICH WILL NOT BE USED.

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1. ELIGIBLE CLAIMANTS (Who Should File A Claim) Continued:
•

•

The executor or administrator of the deceased veteran's estate, or person acting for the deceased veteran's estate. A family
member of the veteran who has paid for the burial or funeral expenses will be considered acting for the veteran's estate for
burial benefit purposes only.
For purposes of this application, legal union means a formal relationship between the veteran and the survivor that existed on
the date of the veteran's death, was recognized under the law of the State in which the couple formalized to relationship and was
evidenced by the State's issuance of documentation memorializing the relationship.

If the veteran's remains are unclaimed, VA will pay the person or entity that provided burial services for the remains of an unclaimed
veteran.
NOTE: Claimant Social Security Number and date of birth are not required when claiming unclaimed remains, or if the claimant is a
firm, corporation, or state agency.
2. TIME LIMIT FOR FILING A CLAIM: claim for non-service-connected burial allowance must be filed with VA within 2 years
after the date of the veteran's permanent burial or cremation. If a veteran's discharge was corrected after death to "Under Conditions
Other Than Dishonorable," the claim must be filed within 2 years after the date of correction. There is no time limit for the serviceconnected burial allowance, plot or interment allowance, VA hospitalization death burial allowance, or reimbursement of
transportation expenses.
3. BURIAL ALLOWANCE: A one-time benefit payment payable toward the expenses of the funeral and burial of the veteran's
remains. Burial includes all legal methods of disposing of the veteran's remains including, but not limited to, cremation, burial at
sea and medical school donation. (See evidence table for more information.)
4. PLOT OR INTERMENT ALLOWANCE: A one-time benefit payment payable toward:
(1) Expenses incurred for the plot or interment if the burial was not in a national cemetery under the jurisdiction of the United
States and non-service-connected burial or VA hospitalization death burial allowance is granted; OR
(2) Expenses are payable if non-service-connected burial is granted and veteran was buried in a State-owned cemetery or subsection used solely for the remains of persons and meets eligibility for burial in a national cemetery.
"Plot" means the final disposition site of the remains, whether it is a grave, mausoleum vault, columbarium niche, or similar place.
"Interment" means the burial of casketed remains in the ground or the placement of cremated remains into a columbarium niche.
5. TRANSPORTATION REIMBURSEMENT: When transportation reimbursement is allowable, VA may pay for expenses
relating to the transportation of the veteran's remains. This includes the pickup of the remains and the transportation of the veteran's
remains to his or her final resting place. Claims for transportation reimbursement benefits must include a statement of account
showing itemized transportation charges.
VA may pay transportation reimbursement only when one of the following eligibility requirements are met:
•

Service-connected burial allowance granted, or the veteran was in receipt of VA disability compensation and burial was in a
national cemetery; OR

•

Non-service-connected burial allowance granted, and the veteran was in receipt of VA disability compensation and burial was
in a national cemetery; OR
Burial for veteran's unclaimed remains granted and burial was in a national cemetery; OR
VA hospitalization death burial allowance granted.

•
•

6. PROOF OF DEATH TO ACCOMPANY CLAIM: Death in a government institution does not need to be proven. In other cases,
the claimant must forward a copy of the public record of death. If the proof of death has previously been furnished to VA, it does
not need to be submitted again.
Claims for service-connected burial allowance must include the veteran's cause of death.
7. RESPONSIBLE FOR (LEGALLY INCURRED) EXPENSES: The claimant (you) have already paid or owe the burial
expenses for the benefit being claimed and is legally the responsible party for the debt. By checking "Yes" on the form, you are
certifying that this statement is true. If filing as an executor of the veteran's estate, by checking "Yes," you certify that the veteran
paid the burial prior to his or her death or funds from the estate were used as payment.
8. SERVICE RECORD: The original or certified copy of the veteran's service separation document (DD214 or equivalent) which
contains information as to the length, time and character of service will permit prompt processing. Service documents will not be
returned. If the return was receiving VA benefits, this is not required with your application.
SUBMITTING A CLAIM
When submitting a claim(s) for Burial Benefits the following information tells you what you need to do and what VA will do during
the FDC Program (Optional Expedited Process) or the Standard Claim Process:
9. HOW TO SUBMIT A CLAIM: Submit your claim on a VA Form 21P-530EZ, Application for Burial Benefits (attached). Make
sure you complete and sign your application.
10. WHAT YOU NEED TO DO: The tables beginning on page 3 describes the information and evidence you need to submit
based on if you wish to have your claim considered in the FDC Program (Optional Expedited Process) or in the Standard
Claim Process. You will need to indicate how you want your claim to be processed by checking the appropriate box in Section
VI on page 7 of this form.
VA FORM 21P-530EZ, XXXX

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FDC Program (Optional Expedited Process)
You must submit:

·
·
·
·

Standard Claim Process
Please submit a complete signed VA Form 21P-530EZ,
Application for Burial Benefits, that includes any required
evidence listed in the tables below.

A signed and FULLY COMPLETE VA Form 21P-530EZ,
Application for Burial Benefits
Required evidence for each burial benefit claimed (see tables
below)

If you know of any evidence not in your possession and want VA
to try to get it for you;

Complete veteran and claimant information
Proof of veteran's death, including the cause of death, if
You must:
claiming service-connected burial allowance. If the veteran was
· Complete and sign VA Form 21-4142 and VA Form 21-4142a,
seen outside of the VA, you must include copies of any
identifying any private medical records you wish VA to request
medical records from a private medical provider or provide a
for you
completed VA Form 21-4142, Authorization to Disclose
· Give VA enough information about other relevant evidence so
Information to the Department of Veterans Affairs (VA) and
that we can request it from the person or agency that has it
VA Form 21-4142a, General Release for Medical Provider
Information to the Department of Veterans Affairs (VA), with
your application for VA to request the records on your behalf
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
· An itemized statement of account, if claiming transportation
reimbursement
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure we
NOTE: If you decide to submit your claim through the FDC
receive all requested records that are not in the possession of a
Program, please indicate FDC in Section VI of the application on Federal department or agency.
page 7.
You must:

·

You are strongly encouraged to:

Send the above information and any specific evidence listed
below for the burial benefit(s) claimed along with your claim
form

·

Send any information or evidence as soon as you can

You have up to one year from the date we receive the claim to
submit the information and evidence necessary to support your
If you submit additional information or evidence after you submit claim. If within 30 days, you do not provide any evidence or do
your "fully developed" claim, then VA will remove the claim from not provide us with the information requested to assist you with
obtaining evidence, we may decide your claim prior to the
the FDC Program (Optional Expedited Process) and process it in
expiration of the one year period. If we decide the claim before
the Standard Claim Process. If we decide your claim before one
one year from the date we receive the claim, you will still have the
year from the date we receive the claim, you will still have the
remainder of the one-year period to submit additional information remainder of the one year period to submit additional information
or evidence necessary to support the claim.
or evidence necessary to support the claim.
11. HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM: The table below describes the information and
evidence VA will assist you in obtaining based on whether you wish to have your claim considered in the FDC Program (Optional
Expedited Process) or in the Standard Claim Process.
FDC Program (Optional Expedited Process)

Standard Claim Process

VA will:

·

·

VA will:

Retrieve relevant records from a Federal facility, such as a VA
Medical Center, that you adequately identify and authorized
VA to obtain.
Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your claim.

·
·
·

Retrieve relevant records from a Federal facility, such as a VA
Medical Center, that you adequately identify and authorized VA
to obtain.
Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your claim.
Make every reasonable effort to obtain relevant records not held
by a Federal facility that you adequately identify and authorize
VA to obtain. These may include records from State or local
governments and privately held evidence and information you
tell us about, such as a private doctor or hospital records from
current or former employers.

12. WHERE TO SEND INFORMATION AND EVIDENCE: You may send your application and any evidence in support of your
claim by using any of the following methods shown in the table below.
MAIL TO
Department of Veterans Affairs
Pension Claims
Intake Center
PO Box 5365
Janesville, WI 53547-5365
VA FORM 21P-530EZ, XXXX

FAX TO

ONLINE

844-655-1604 (Toll Free) OR
For Foreign Claims 248-524-4260

https://www.va.gov/

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13. WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM: The tables below show what evidence you must
provide and eligibility information to support your claim for burial benefits.
EVIDENCE TABLES
Non-Service-Connected Burial Allowance
To support a claim for non-service-connected burial allowance, the evidence mush show:
• VA received a burial claim for non-service-connected burial allowance no later than two years after the burial or cremation of
the veteran; AND
• You are an eligible claimant authorized burial benefits; AND

• Proof of veteran's death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the
estate and is applying on behalf of the veteran who incurred the expenses; AND
• Verification of veteran's military service (only if veteran was not in receipt of VA benefits at time of death; AND
• On the date of death, the veteran:
• Was in receipt of VA disability compensation or VA pension; OR
• Had a claim pending which would have resulted in entitlement to VA disability compensation or VA pension; OR
• Was entitled to receive VA disability compensation or VA pension but decided to receive military retirement or disability
pay in place of VA disability compensation check.
Service-Connected Burial Allowance
To support a claim for service-connected burial allowance, the evidence must show:
• VA received a burial claim for service-connected burial allowance; AND
• You are an eligible claimant authorized burial benefits; AND

• Proof of veteran's death including the cause of death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the
estate and is applying on behalf of the veteran who incurred the expenses; AND
• Verification of the veteran's military service (only if the veteran was not in receipt of VA benefits at the time of death; AND
• If your claim is based on a service-connected disability established during the veteran's lifetime, the evidence must show:
• The veteran had a service-connected disability(ies) that was/were either the principal or contributory cause of the veteran's
death; OR
• If your claim is based on a disability that was not established as service-connected during the veteran's lifetime or for which
the veteran did not file a claim during his or her lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active military service, or an event in service that caused an
injury or disease; AND
• A physical or mental disability that was either the principle and contributory cause of death. This may be shown by
medical evidence or by lay evidence of persistent and recurrent symptoms of a disability that were visible or observable
; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in military service.
Medical records or medical opinions are generally required to establish this relationship.
VA Hospitalization Death Burial Allowance
In order to support a claim for VA hospitalization death burial allowance, the evidence must show:
• VA received a burial claim for VA hospitalization death burial allowance; AND
• You are an eligible claimant authorized burial benefits; AND

• Statement certifying that the claimant incurred burial expenses of the deceased veteran, or claimant is the executor of the
estate and is applying on behalf of the veteran who incurred the expenses; AND
• Verification of veteran's military service; AND
• Proof veteran's death occurred at VA medical center, State Veterans home, or nursing home under VA contract. For VA
hospitalization, for the purpose of this burial benefit, VA hospitalization is met, if at the time of death, the veteran:
• Was properly admitted to a VA facility; OR
VA FORM 21P-530EZ, XXXX

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EVIDENCE TABLES (Continued)
VA Hospitalization Death Burial Allowance (Continued)
• Was transferred or admitted to a non-VA facility for hospital care under VA contract; OR
• Was transferred or admitted to a nursing home for nursing home care at the expense of the VA contract; OR
• Was traveling under proper prior authorization to or from a specified place for purpose of examination, treatment or care,

at VA expense; OR
• Was transferred or admitted to a State nursing home at the expense of the VA, under VA contract; OR
• Was a patient in a State Veteran's home; AND

• Total cost of the veteran's burial is listed on the form.
Unclaimed Remains
In order to support a claim for unclaimed remains, the evidence must show:
• VA received a burial claim for veteran's unclaimed remains no later than two years after the burial or cremation of the
veteran; AND
• You are an eligible claimant authorized burial benefits; AND

• Proof of veteran's death; AND
• Statement certifying that the claimant incurred burial expenses of the deceased veteran; AND
• The remains of the deceased veteran have not been claimed by relatives or friends; AND
• There are not sufficient resources available in the veteran's estate to cover the burial and funeral expenses.
Plot or Interment Allowances
In order to support a claim for plot or interment allowance, the evidence must show:
• VA received a burial claim for plot or interment allowance; AND
• You are an eligible claimant authorized burial benefits; AND

• Proof of veteran's death; AND
• Statement certifying that the claimant incurred plot or interment expenses, or claimant is the executor of the estate and is
applying on behalf of the veteran who incurred the expenses; AND
• Veterans burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery.

Transportation Reimbursement
To support your claim for transportation reimbursement, the evidence mush show:
• VA received a burial claim for transportation reimbursement; AND
• You are an eligible claimant authorized burial benefits; AND

• Proof of veteran's death; AND
• Statement certifying that the claimant incurred transportation expenses of the deceased veteran, or claimant is the executor of
the estate and is applying on behalf of the veteran who incurred the expenses; AND
• An itemized receipt or statement, preferably on letterhead that includes the:
• Name of the deceased veteran; AND
• Specific transportation costs incurred; AND
• Date of the services rendered; AND
• Name of the individual who paid the costs.
HOW VA DETERMINES THE EFFECTIVE DATE
Burial benefits are based on the date of the veteran's death and the death date we receive your claim. The veteran's death certificate is
relevant evidence used in determining the effective date of any benefits we award.
VA FORM 21P-530EZ, XXXX

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OMB Approved No. 2900-0003
Respondent Burden: 30 Minutes
Expiration Date: XXXXXXXX

APPLICATION FOR BURIAL BENEFITS
(Under 38 U.S.C. Chapter 23)

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

IMPORTANT - Please read the Privacy Act and Respondent Burden on page 8 before
completing the form. SELECT THE TYPE OF CLAIM PROGRAM/PROCESS (Check the
appropriate box. See instructions pages.)
NOTE: You can either complete the form online or by hand. If you complete the form online, you
may submit it at VA.gov to expedite processing. If you complete the form by hand, please print
the information requested in ink, neatly, and legibly to help process the form.
SECTION I - PERSONAL IDENTIFICATION OF VETERAN
1. FIRST, MIDDLE INITIAL, LAST NAME OF THE DECEASED VETERAN NAME
2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER
C/CSS CLAIMANT'S PERSONAL INFORMATION

4. CLAIMANT'S NAME (First, middle initial, last)

5. CLAIMANT'S SOCIAL SECURITY NUMBER

6. CLAIMANT'S DATE OF BIRTH (See instructions for exceptions.)
Month

Day

Year

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

8. PREFERRED TELEPHONE NUMBER (Include Area Code)

9. PREFERRED E-MAIL ADDRESS

10. RELATIONSHIP OF CLAIMANT TO DECEASED VETERAN (Check one)
SPOUSE OR SURVIVOR OF
LEGAL UNION

EXECUTOR/ADMINISTRATOR OF ESTATE OR PERSON ACTING FOR THE ESTATE

CHILD

FUNERAL HOME OR CLAIMANT WHO PAID FOR BURIAL OF UNCLAIMED REMAINS

PARENT

SECTION II - INFORMATION REGARDING VETERAN

11. DATE OF BIRTH
Month

12. DATE OF DEATH

Day

Year

Month

Day

13. DATE OF BURIAL

Year

Month

Day

Year

SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)
14A. ENTERED SERVICE
DATE

PLACE

14B. SERVICE
NUMBER

14C. SEPARATED FROM SERVICE
DATE

PLACE

14D. GRADE, RANK OR RATING,
ORGANIZATION AND BRANCH OF SERVICE

15. IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME

VA FORM
XXXX

21P-530EZ

SUPERSEDES VA FORM 21P-530, APR 2017,
WHICH WILL NOT BE USED

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VETERAN'S SSN

SECTION III - CLAIM FOR BURIAL ALLOWANCE

16B. WHERE DID THE VETERAN'S DEATH OCCUR? (Check one)

16A. SELECT TYPE OF BURIAL ALLOWANCE YOU ARE CLAIMING

(May apply for more than one.)

NURSING HOME/FACILITY (NOT PAID BY VA) OR VETERANS RESIDENCE

NON-SERVICE-CONNECTED BURIAL ALLOWANCE

NURSING HOME/FACILITY (PAID BY VA)*

SERVICE-CONNECTED BURIAL ALLOWANCE

VA MEDICAL CENTER*
STATE VETERANS FACILITY*

VA HOSPITALIZATION DEATH BURIAL ALLOWANCE*

OTHER (Specify place of death.)*

UNCLAIMED REMAINS OF VETERAN
(If claimed, you must answer question 16B,)

*Please provide veteran's specific place of death including the name and location of the nursing
home, VA Medical Center or state veteran facility

(If VA Hospitalization Death is checked, provide actual burial cost.)

$
17. IF YOU ARE THE DECEASED VETERAN'S SPOUSE, DID YOU PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
18A. ARE YOU RESPONSIBLE FOR THE VETERAN'S BURIAL EXPENSES?

YES

YES

NO

NO

18B. DO YOU CERTIFY THE REMAINS OF THE DECEASED VETERAN HAVE NOT BEEN CLAIMED BY RELATIVES OR FRIENDS AND THERE ARE NOT SUFFICIENT
RESOURCES AVAILABLE IN THE VETERAN'S ESTATE TO COVER THE BURIAL AND FUNERAL EXPENSES? (Required only if claiming unclaimed remains of veteran.)
YES

NO

SECTION IV - CLAIM FOR PLOT OR INTERMENT ALLOWANCE
19. PLACE OF BURIAL PLOT, INTERMENT SITE, OR FINAL RESTING PLACE OF DECEASED VETERAN'S REMAINS
CEMETERY/GRAVEYARD

PRIVATE RESIDENCE

MAUSOLEUM/VAULT/TOMB/CRYPT

OTHER (Specify)

20A. ARE YOU RESPONSIBLE FOR THE VETERAN'S PLOT OR INTERMENT
EXPENSES?
YES

NO

20B. WAS VETERAN BURIED IN A NATIONAL CEMETERY, OR ONE OWNED BY
THE FEDERAL GOVERNMENT?
YES

NO

20C. WAS THE VETERAN BURIED IN A STATE VETERANS CEMETERY?
YES

NO

21A. DID A FEDERAL/STATE GOVERNMENT OR THE VETERAN'S 21B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION
EMPLOYER CONTRIBUTE TO THE BURIAL?
YES

$

NO (If "Yes," complete Item 18B)

SECTION V - CLAIM FOR TRANSPORTATION REIMBURSEMENT

22. ARE YOU RESPONSIBLE FOR THE VETERAN'S TRANSPORTATION EXPENSES FROM THE PLACE OF DEATH TO THE FINAL RESTING PLACE?

(You must include an itemized receipt.)
YES

NO

SECTION VI - CLAIM CERTIFICATION AND SIGNATURES (MUST COMPLETE)
CLAIMANT CERTIFICATION AND SIGNATURE

I WANT my claim processed under the FDC program. I CERTIFY and authorize the release of information. I CERTIFY that the statements in
this document are true and complete to the best of my knowledge. I AUTHORIZE any person or entity, including but not limited to any
organization, service provider, employer, or government agency, to give the Department of Veterans Affairs any information about me and the
veteran, and I WAIVE any privilege which makes the information confidential. I CERTIFY I have received the notice attached to this application
titled, Application for Burial Benefits, and, I CERTIFY I have enclosed all the information or evidence that will support my claim, to include an
identification of relevant records available at a Federal facility such as a VA medical center; or, I have no additional information or evidence to
give VA to support my claim.
I do not want my claim processed under the FDC program. I am indicating I want my claim processed under the standard claim process because I
plan to submit further evidence in support of my claim.
23A. SIGNATURE OF CLAIMANT (REQUIRED) (Sign in ink) (If signed using an "X",
complete Items 25A through 26B.) (If signing for a firm, corporation, or State agency,
complete Items 24A through 24B.)

23B. PRINTED NAME OF CLAIMANT

24A. FULL PRINTED NAME AND ADDRESS OF PERSON, FIRM,
CORPORATION, OR STATE AGENCY SIGNING AS CLAIMANT
(If different from Item 7.)

24B. OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF
FIRM, CORPORATION OR STATE AGENCY

VA FORM 21P-530EZ, XXXX

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VETERAN'S SSN

SECTION VII - WITNESSES TO SIGNATURE
NOTE - If the claimant signed above using an "X", a signature must be witnessed by two persons to whom the person making the statement and the
signatures and addresses of such witnesses must be shown below.

25A. SIGNATURE OF WITNESS (Sign in ink.) (Only sign if the signature in

25B. PRINTED NAME AND ADDRESS OF WITNESS

26A. SIGNATURE OF WITNESS (Sign in ink.) (Only sign if the signature in

26B. PRINTED NAME AND ADDRESS OF WITNESS

Item 23A used an "X")

Item 23A used an "X")

SECTION VIII - ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (REQUIRED ONLY IF ITEM 23A IS BLANK)
I CERTIFY THAT by signing on behalf of the claimant, I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I UNDERSTAND that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also
understand that VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf
of the claimant if necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification
Number (TIN); a certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature
and a date/time stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the
claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person
responsible for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such
authorization.
27A. ALTERNATE SIGNER SIGNATURE (REQUIRED) (Sign in ink.)

27B. DATE SIGNED

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside the
Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system
of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal
Register. The requested information is considered relevant and necessary to determine maximum benefits under the law and is required to obtain
benefits. Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility for burial benefits. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete 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.
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.
DEPARTMENT OF VETERANS AFFAIRS HEADSTONES AND MARKERS

The Department of Veterans Affairs will furnish, upon request, a Government headstone or marker at the expense of the United States for the
unmarked graves of certain individuals eligible for burial in a national cemetery, but not buried there. These individuals may include any veterans with
an other than dishonorable discharge who dies after service or any servicemember who dies on active duty. Certain other individuals may also be
eligible for the headstone or marker. Headstones or Markers for all individuals in a national or post cemetery are furnished automatically without a
request from the family. For additional information on burial benefits go to the web site, www.cem.va.gov/bbene_burial.asp. To obtain VA Form
40-1330, Application for Standard Government Headstone or Marker go to www.va.gov/vaforms or contact your local VA regional office. The address
of that office can be found at www.va.gov/directory.

VA FORM 21P-530EZ, XXXX

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