Form VA 40-10088 VA 40-10088 Request for Reimbursement of Casket/Urn

Form Approved, OMB No. 2900-0799
Respondent Burden: 10 minutes
Expiration Date: XXX, 20XX

REQUEST FOR REIMBURSEMENT OF CASKET/URN
(For a deceased Veteran buried in a VA National, State, or Tribal Cemetery with no next-of-kin and insufficient resources for burial)
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average 10 minutes per response. Statutory
authority for casket or urn reimbursement is 38 U.S.C. 2306 for deaths occurring on or after January 10, 2014 if interred in a VA national cemetery
or on or after December 14, 2016 if interred in a VA-funded State or Tribal cemetery. The information requested is approved under OMB Control
Number 2900-0799 and is necessary to allow a person authorized to purchase a casket or urn for the decedent to request reimbursement for the cost of
such a burial receptacle. The National Cemetery Administration does not give, sell or transfer any personal information outside of the agency. VA may
not conduct or sponsor, and you are not required to respond to, this collection of information unless it displays a valid OMB Control Number.
Responding to this collection is voluntary.
PRIVACY ACT INFORMATION: VA is asking you to provide the information on this form under 38 U.S.C. Section 2306 in order for VA to obtain
information sufficient to provide reimbursement for the purchase of a casket or an urn, if that Veteran has no next-of-kin that is willing or able to pay for
the burial and insufficient resources for burial. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine
use" disclosure of the information as outlined in the applicable Privacy Act system of records notice (48VA40B, Veterans (Deceased) Headstone or
Marker Records - VA, as published in the Federal Register on August 26, 1975, (40 FR 38095)). Providing the requested information is voluntary, but if
any or all of the requested information is not provided, it may delay or result in denial of your request for reimbursement. VA may also use this
information to identify Veterans and persons claiming or receiving VA benefits and their records and for other purposes authorized or required by law.

PART I - APPLICATION AND CERTIFICATION (Completed by the Applicant)
INSTRUCTIONS FOR SUBMITTING A REQUEST FOR REIMBURSEMENT: Type or print clearly all information required. This part
serves as a means for applicants to certify information that is necessary to claim reimbursement for a casket or urn purchased for unclaimed deceased
Veterans with insufficient resources for burial. To apply for reimbursement, applicants must also provide the invoice which clearly indicates the
purchase price of the casket or urn purchased by the applicant. Applications and invoices should be submitted to the National Cemetery
Administration Finance Service via fax 1-540-658-7281 or via mail to National Cemetery Administration, Attention: Casket/Urn
Reimbursements, P.O. Box 335, Garrisonville, VA 22463-0335.
Applicants must also have a Vendor ID on file with the VA Finance Service Center (FCS). Applicants who do not have a Vendor ID may submit,
either before or after the interment, a completed and signed FSC Vendor File Request Form (VA Form 10091) to the NCA Finance Service at the
above address (Attention: Casket and Urn Program). Applicants may download the form at http://vaww.va.gov/vaforms/va/pdf/VA10091.pdf.
PLEASE NOTE: VA will not process the reimbursement unless the applicant has completed all requirements in Parts I of this form and submitted
all required documentation for reimbursement.
1. NAME OF DECEASED VETERAN

2. SOCIAL SECURITY NUMBER 3. SERVICE NUMBER (If available)

4. DATE OF DEATH

5. RACE OR ETHNICITY (Optional. You may select more than one. Information will be used for statistical purposes only.)
AMERICAN INDIAN OR ALASKA NATIVE

ASIAN

NOT HISPANIC OR LATINO

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

6. SEX (Optional. Information will be used for statistical purposes only)
MALE

BLACK OR AFRICAN AMERICAN

HISPANIC OR LATINO
WHITE

7. AGE AT TIME OF DEATH (Optional)

FEMALE

8. NAME OF FUNERAL HOME REPRESENTATIVE (If applicable)

10. ADDRESS OF FUNERAL HOME

9. TELEPHONE NUMBER OF FUNERAL HOME

11. NAME OF APPLICANT

13. ADDRESS OF APPLICANT

12. TELEPHONE NUMBER OF APPLICANT

14. APPLICANT E-MAIL ADDRESS (Optional)

15. PLEASE INCLUDE THE FOLLOWING ATTACHMENTS. (Please ensure decedent's name and/or DECEDENT ID appears on each attachment.)
INVOICE/BILL OF SALE SHOWING MODEL NUMBER AND PURCHASE PRICE OF CASKET OR URN
FSC VENDOR FILE REQUEST FORM (VA FORM 10091) If previously enrolled provide Vendor ID:
VA FORM
MAR 2020

40-10088

By signing below I certify the following:
I. I cannot identify the Veteran's next-of-kin or an identified next of kin is unwilling or unable to assume responsibility for the
deceased Veteran's burial arrangements.
II. I have followed applicable state or local law relating to the disposition of unclaimed remains.
III. To the best of my knowledge, sufficient resources are otherwise unavailable to furnish the casket or urn.
16. SIGNATURE OF PERSON AUTHORIZED TO CERTIFY (Ink signature)

17. DATE

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.

PART II - CEMETERY OFFICIAL OBSERVATION OF BURIAL CONTAINER
(For Completion by VA National, State, or Tribal Cemetery Official)
1. BEFORE REIMBURSEMENT FOR THE CASKET OR URN CAN BE PROCESSED, ALL OF THE FOLLOWING QUALITY STANDARDS FOR THE BURIAL
RECEPTABLE MUST BE OBSERVED:
URN
CASKET
(Must be of durable material. Select one)
STANDARD SIZE (Exterior dimensions are generally 82 X 28 inches)

PLASTIC

METAL

CONSTRUCTED OF 20 GUAGE OR THICKER METAL

WOOD

CERAMIC/STONE

CONTAINS A GASKETED SEAL, AND IS NOT LEAKING

OTHER

SEALED, NOT LEAKING

HAS FIXED RAILS OR SWING ARM HANDLES
HOLDS THE WEIGHT OF THE DECEDENT'S REMAINS
THE CASKET/URN EXHIBITS ALL OF THE LISTED QUALITY STANDARDS
THE CASKET/URN DOES NOT EXHIBIT ALL OF THE
LISTED QUALITY STANDARDS (Please Explain)
2. PRINTED NAME OF VA NATIONAL, STATE, OR
TRIBAL CEMETERY OFFICIAL

3. CEMETERY NAME

4. CEMETERY STATION NUMBER

5. CEMETERY STATE

6. SIGNATURE OF VA NATIONAL, STATE OR TRIBAL CEMETERY OFFICIAL (Ink signature)

7. DATE

8. APPLICANT ACKNOWLEDGMENT OF OBSERVATIONS (SIGNATURE) (Ink signature)

9. DATE

VA FORM 40-10088, MAR 2020, Page 2