VA40-1330M Claim for Government Medallion For Placement in a Privat

GENERAL INFORMATION SHEET
CLAIM FOR GOVERNMENT MEDALLION TO AFFIX TO A PRIVATE MARKER
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 response 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)
VA will furnish a medallion 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 10 of the claim for further information).

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 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. Any Servicemember of the Armed Forces of the United States who served on or
after April 6, 1917, and died on active duty and is buried in a private cemetery in a grave marked with a privately purchased headstone or marker. 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 bearing the signature of the
current president, to honor the memory of Veterans discharged under other than dishonorable conditions. VA will provide the applicant with a PMC if the Veteran is
eligible for a headstone, marker, or medallion. The applicant may request additional PMCs by indicating how many in block 17 of this form. Applicants may use a
VA Form 40-0247, Presidential Memorial Certificate Request Form to order additional PMCs to other addresses.
HOW TO SUBMIT A CLAIM - Please attach a copy of the deceased Veteran's discharge certificate (DD Form 214 or equivalent), the VA Pre-Need Eligibility
Determination letter, 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.
ELECTRONICALLY submit your claim and
supporting documents by using Quick Submit
at access.va.gov. You will be instructed to
register during your first sign-on attempt. Multiple
claims can be submitted electronically via Quick Submit.

If you prefer, you may
MAIL claims to: NCA FP Evidence Intake Center
PO Box 5237
Janesville, WI 53547

FAX VA Form 40-1330M 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,
i.e., disconnect the call and redial for each submission.

VA will furnish a medallion only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED - The claimant signs in block 18; the cemetery or other responsible official signs in block 23. If there is no official on duty at the
cemetery, the signature of the person responsible for the property listed in block 22 is required. Entries of "None," "Not Applicable," or "NA" will not be accepted.
ASSISTANCE NEEDED Should you have questions when filling out this form, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or
at: ask.va.gov . 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.
DELIVERY - VA will ship the medallion without charge to the name/address designated in Block 20. 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 will be 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
AUG 2022

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)
Quick Submit: access.va.gov or Fax Number: 1-800-455-7143
From:
Sender's Phone Number:
Sender's Fax Number:
Total No. of Pages (including cover sheet):

This optional cover sheet is provided for your convenience.
Include all supporting documents with this application (i.e., DD Form 214 or equivalent discharge documents). If you do not
have supporting documents, please submit your application anyway and VA will request documents from the National
Personnel Records Center for you, if necessary. Please note, this may result in a longer processing time.
You may:
ELECTRONICALLY submit your claim and supporting documents by using Quick Submit at access.va.gov.
You will be instructed to register during your first sign-on attempt. Multiple claims can be submitted electronically via
Quick Submit.
OR
MAIL claim to NCA FP EVIDENCE INTAKE CENTER
PO BOX 5237
JANESVILLE, WI 53547

OR
FAX VA Form 40-1330M and supporting documents to: 1-800-455-7143. This fax line is dedicated to the transmission of
applications for the headstone, marker, or medallion. Applications for other Government benefits will not be accepted.
IMPORTANT: If faxing more than one claim - fax each claim package (claim plus supporting documents) individually
(disconnect the call and redial for each submission).

Form approved, OMB No. 2900-0222
Expiration Date: July 31, 2024
Respondent Burden: 15 minutes

CLAIM FOR GOVERNMENT MEDALLION FOR
PLACEMENT IN A PRIVATE CEMETERY
1. CHECK BOX BELOW IF REMAINS ARE NOT BURIED AND
EXPLAIN BELOW (e.g., buried at sea, remains scattered, etc.)

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.

REMAINS NOT BURIED

2. NAME OF DECEASED VETERAN
FIRST (Or Initial)

MIDDLE (Or Initial)

LAST

SUFFIX

3. THERE MUST BE A SET HEADSTONE, MAUSOLEUM, OR
CRYPT IN PLACE TO AFFIX THE MEDALLION. IS GRAVE
CURRENTLY MARKED WITH A PRIVATELY PRUCHASED
PERMANENTAND DURABLE MARKER?
YES

4. RACE OR ETHNICITY (You may select more than one. Information will be used for statistical purposes only.)
NOT HISPANIC OR LATINO
ASIAN OR ASIAN AMERICAN

NO

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

AMERICAN INDIAN OR ALASKA NATIVE

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

BLACK OR AFRICAN AMERICAN

WHITE

FEMALE
UNSPECIFIED OR ANOTHER GENDER IDENTITY

HISPANIC OR LATINO

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
6. VETERAN'S SOCIAL SECURITY NO. AND/OR SERVICE NO.
SSN:

7. PLACE OF BIRTH (City and State or Country)

SVC. NO.:

8A. DATE OF BIRTH
MONTH
DAY
YEAR

PERIODS OF ACTIVE MILITARY DUTY

8B. DATE OF DEATH
MONTH
DAY
YEAR

9A. DATE(S) ENTERED
MONTH
DAY
YEAR

9B. DATE(S) SEPARATED
MONTH
DAY
YEAR

10. 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

SPACE FORCE

COAST GUARD

PUBLIC HEALTH SVC.

MERCHANT MARINE

NAVY

NATL. OCEANIC AND ATMOSPHERIC ADMIN.

AIR FORCE

ARMY AIR FORCES (WWII)

OTHER (Specify)

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

MEDIUM (M3)

SMALL (M1)

12. APPLICANT IS:
FAMILY MEMBER (Specify relationship)

PERSONAL REPRESENTATIVE (Person responsible for decisions
concerning burial of decedent; include written authorization)

VETERANS SERVICE OFFICER

OTHER (Specify)

13. IF REMAINS ARE UNCLAIMED, APPLICANT IS:
FUNERAL HOME
(that received remains)

CEMETERY
(where remains are buried)

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

15. DAYTIME PHONE NO.
OF APPLICANT

16. E-MAIL ADDRESS (Optional)

17. PRESIDENTIAL MEMORIAL CERTIFICATE (bearing the signature of the current President) the number you request to be mailed to you. VA will send one certificate if no quantity is indicated and
"none" is not selected.
NUMBER REQUESTED
NONE

CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in Block
22 at no expense to the Government, and that I (or the party listed in Block 20) 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 the Veteran 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.
18. SIGNATURE OF APPLICANT

19. DATE (MM/DD/YYYY)

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

21. DAYTIME PHONE NO.
(Include Area Code)

22. NAME AND ADDRESS OF CEMETERY WHERE PRIVATELY PURCHASED
HEADSTONE, MARKER, MAUSOLEUM, OR CRYPT TO AFFIX
THE MEDALLION 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.
23. SIGNATURE OF CEMETERY OFFICIAL

VA FORM
AUG 2022

40-1330M

24. DATE (MM/DD/YYYY)

ALL PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE