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
• 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: Supplemental 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.

VA FORM
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21P-530EZ

SUPERSEDES VA FORM 21P-530, NOV 2021

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GENERAL INFORMATION
ELIGIBLE CLAIMANTS (Who Should File A Claim):
Check the appropriate box on the form (block 13) 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
• 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.
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 service-connected burial allowance, plot or interment allowance, nonservice-connected burial allowance based upon VA hospitalization death, or reimbursement of transportation expenses.
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.)
PLOT OR INTERMENT ALLOWANCE: A one-time benefit payment payable toward:
(1) Expenses incurred for the plot or interment of a Veteran who was eligible for burial in a national cemetery if the actual burial was not in a national
cemetery under the jurisdiction of the United States and non-service-connected burial allowance is granted; OR
(2) Expenses are payable if non-service-connected burial allowance is granted and veteran was buried in a State-owned cemetery or sub-section used
solely for the remains of such persons or other individuals as authorized within 38 U.S.C. 2303(b)(1) 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.
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 or covered
Veteran's cemetery; OR
• Non-service-connected burial allowance granted, and the veteran was in receipt of VA disability compensation and burial was in a national or
covered Veteran's cemetery; OR
• Burial for veteran's unclaimed remains granted and burial was in a national or covered Veteran's cemetery; OR
• VA hospitalization death
NOTE: a covered Veterans' cemetery is defined as a Veterans' cemetery in which a deceased Veteran is eligible to be buried that is owned by a
State or is on trust land owned by, or held in trust for, a tribal organization, and for which the Secretary has made a grant under 38 U.S.C. 2408.
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.
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.
SERVICE RECORD: A photocopy of the veteran's DD214 (or equivalent) for all periods of military service will permit prompt processing. You may
request a copy of the DD214 through the National Archives' National Personnel Records Center (NPRC) using SF 180 (Nov 2015 version), Request
Pertaining to Military Records, (available at https://www.archives.gov/) or through your local public custodian of records. Service documents will not be
returned. If the veteran was receiving VA benefits, this is not required with your application.

VA FORM 21P-530EZ, XXX XXXX

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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:
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.
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 VII on page 7 of this form.

FDC Program (Optional Expedited Process)
You must submit:
• A signed and FULLY COMPLETE VA Form 21P-530EZ,
Application for Burial Benefits
• Required evidence for each burial benefit claimed (see tables below)
• Complete veteran and claimant information
• Proof of veteran's death, including the cause of death, if claiming
service-connected burial allowance. If the veteran was seen outside of
the VA, you must include copies of any medical records from a
private medical provider or provide a completed VA Form 21-4142,
Authorization to Disclose Information to the Department of Veterans
Affairs (VA) and 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
• An itemized statement of account, if claiming transportation
reimbursement
NOTE: If you decide to submit your claim through the FDC Program,
please indicate FDC in Section VII of the application on page 7.
You must:
• Send the above information and any specific evidence listed below
for the burial benefit(s) claimed along with your claim form
If you submit additional information or evidence after you submit your
"fully developed" claim, then VA will remove the claim from the FDC
Program (Optional Expedited Process) and process it in the Standard Claim
Process. If we decide your claim before one year from the date we receive
the claim, you will still have the remainder of the one-year period to submit
additional information or evidence necessary to support the claim.

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.
If you know of any evidence not in your possession and want VA to try to
get it for you;
You must:
• Complete and sign VA Form 21-4142 and VA Form 21-4142a,
identifying any private medical records you wish VA to request for
you
• Give VA enough information about other relevant evidence so that
we can request it from the person or agency that has it
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 notify you and
provide you with an opportunity to submit the information or evidence. It
is your responsibility to make sure we receive all requested records that
are not in the possession of a Federal department or agency.
You are strongly encouraged to:
• 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 claim. If within 30
days, you do not provide any evidence or do not provide us with the
information requested to assist you with obtaining evidence, we may
decide your claim prior to the expiration of the one year period. If we
decide the claim before one year from the date we receive the claim, you
will still have the remainder of the one year period to submit additional
information or evidence necessary to support the claim.

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)
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.

Standard Claim Process
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.
• 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.

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.

VA FORM 21P-530EZ, XXX XXXX

MAIL TO

ONLINE

Department of Veterans Affairs
Pension Claims
Intake Center
PO Box 5365
Janesville, WI 53547-5365

https://www.va.gov/

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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 must 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
• At the time 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; OR
• Was hospitalized by VA. 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
• 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

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EVIDENCE TABLES (Continued)
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
• Veterans burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery.
• 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 cemetery as listed in 38 U.S.C. 2303(b)(1).

Transportation Reimbursement
To support your claim for transportation reimbursement, the evidence must 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, XXX XXXX

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OMB Approved No. 2900-0003
Respondent Burden: XX Minutes
Expiration Date: XX/XX/XXXX

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

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

NOTE: You can either complete the form online or by hand. If you complete the form online, you
may submit it at https://www.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 - VETERAN'S INFORMATION
1. LAST NAME OF THE DECEASED VETERAN (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S DATE OF DEATH (MM/DD/YYYY)

6. VETERAN'S DATE OF BURIAL (MM/DD/YYYY)

SECTION II - CLAIMANT'S INFORMATION
7. CLAIMANT'S NAME (First, Middle Initial, Last)

8. CLAIMANT'S SOCIAL SECURITY NUMBER (See instructions for exceptions.)

9. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY) (See instructions for exceptions.)

10. 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

11. TELEPHONE NUMBER (Include Area Code)

12. E-MAIL ADDRESS

13. 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 OTHER THIRD PARTY

PARENT

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

(MM/DD/YYYY)

PLACE

14B. SERVICE
NUMBER

14C. SEPARATED FROM SERVICE
DATE

(MM/DD/YYYY)

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
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21P-530EZ

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VETERAN'S SSN (Pre-populated from Page 6)

SECTION IV - INFORMATION REGARDING FINAL RESTING PLACE
16. PLACE OF BURIAL PLOT, INTERMENT SITE, OR FINAL RESTING PLACE OF DECEASED VETERAN'S REMAINS
CEMETERY/GRAVEYARD

PRIVATE RESIDENCE

MAUSOLEUM/VAULT/TOMB/ENCRYPT

OTHER (SPECIFY)

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

NO

(If "Yes," provide name of cemetery)

18. WAS THE VETERAN BURIED IN A CEMETERY OWNED BY THE STATE OR TRIBAL TRUST LAND?
YES, State Cemetery

YES, Tribal Trust Land

(If "Yes," provide name and zip code of cemetery or Tribal Trust Land below)

NO

Name:

Zip Code:

19A. DID A FEDERAL/STATE GOVERNMENT OR THE VETERAN'S EMPLOYER
CONTRIBUTE TO THE BURIAL?
YES

NO

19B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION

$

(If "Yes," complete Item 19B)

.00

SECTION V - CLAIM FOR BURIAL ALLOWANCE
20B. WHERE DID THE VETERAN'S DEATH OCCUR? (Check One)

20A. SELECT TYPE OF BURIAL ALLOWANCE YOU ARE CLAIMING

(May apply for more than one.)

NON-SERVICE-CONNECTED BURIAL ALLOWANCE

NURSING HOME/FACILITY (NOT PAID BY VA) OR VETERAN'S RESIDENCE

SERVICE-CONNECTED BURIAL ALLOWANCE

NURSING HOME/FACILITY (PAID BY VA)*

UNCLAIMED REMAINS OF THE VETERAN

VA MEDICAL CENTER*

(If claimed, you must answer question 20B.)

STATE VETERANS FACILITY*
OTHER (Specify place of death)*
*Please provide veteran's specific place of death including the name and location of the
nursing home, VA Medical Center or State veteran facility

21. IF YOU ARE THE DECEASED VETERAN'S SPOUSE, DID YOU PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
22A. ARE YOU RESPONSIBLE FOR THE VETERAN'S BURIAL EXPENSES?

YES

YES

NO

NO

22B. DO YOU CERTIFY THE REMAINS OF THE DECEASED VETERAN HAVE NOT BEEN CLAIMED BY RELATIVES OR FRIENDS AND THERE ARE NOT SUFFICENT
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 VI - CLAIM FOR PLOT AND/OR TRANSPORTATION ALLOWANCE
23. ARE YOU RESPONSIBLE FOR THE VETERAN'S PLOT OR INTERMENT EXPENSES?

YES

NO

24. 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 VII - 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.
25A. SIGNATURE OF CLAIMANT (REQUIRED) (Physical Signature OR E-Signature)

25B. PRINTED NAME OF CLAIMANT

26A. FULL PRINTED NAME AND ADDRESS OF PERSON, FIRM, CORPORATION,
OR STATE AGENCY SIGNING AS CLAIMANT (If different from Item 7.)

26B. OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM,
CORPORATION OR STATE AGENCY

(If signed using an "X", complete Items 27A through 28B.) (If signing for a firm,
corporation, or State agency, complete Items 26A through 26B.)

VA FORM 21P-530EZ, XXX XXXX

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VETERAN'S SSN (Pre-populated from Page 6)

SECTION VIII: 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.
27A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in

27B. PRINTED NAME AND ADDRESS OF WITNESS

28A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in

28B. PRINTED NAME AND ADDRESS OF WITNESS

Item 25A used an "X")

Item 25A used an "X")

SECTION IX: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (REQUIRED ONLY IF ITEM 25A 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.
29A. ALTERNATE SIGNER SIGNATURE (REQUIRED only if 25A is blank) (Physical Signature)

29B. DATE SIGNED (MM/DD/YYYY)

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 Veteran Readiness 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 30 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, https://www.cem.va.gov/burial_benefits/index.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.

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