40-10232 Request for Payment of Monetary Allowance for Outer Buri

Form Approved, OMB No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date:

REQUEST FOR PAYMENT OF MONETARY ALLOWANCE FOR OUTER BURIAL RECEPTACLES
(For burials in a cemetery that is the subject of a grant to a State or Tribal Organization
under 38 U.S.C. 2408, in accordance with 38 CFR §38.629(d) and (e))
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-XXXX, and it expires
XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including
suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No.
2900-XXXX in any correspondence. Do not send your completed VA Form 40-10232 to this email address.
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized
under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses as identified in the VA system of records,
13VA047, Individuals Submitting Invoices-Vouchers for Payment and Accounting Transactional Data-VA, as published in the Federal Register
on August 31, 2023 (88 FR 60269). The requested information is considered relevant and necessary to process payment of the monetary
allowance as authorized by 38 U.S.C. 2306(e).
INSTRUCTIONS: Statutory authority for payment of monetary allowance for outer burial receptacles is 38 U.S.C. 2306(e). Type or print
clearly all information required.
Part A: Individuals should use Part A of this form to request payment of the monetary allowance for a privately purchased outer burial
receptacle for burials on or after January 5, 2023 in a cemetery that is the subject of a grant to a State or Tribal Organization under 38 U.S.C.
2408. Applicants must also provide evidence of payment, such as a paid invoice or purchase receipt. Applications and proof of purchase for this
part should be submitted to the National Cemetery Administration, Finance Service via fax 1-314-416-6340 or via mail to National Cemetery
Administration, Attention: VCGP OBR Allowance, P.O. Box 141, Triangle, VA 22172, or via email to [email protected].
Part B: State Agencies and Tribal Organizations should use Part B of this form to request quarterly payment of the monetary allowance for outer
burial receptacles placed at the time of interment on or after January 5, 2023 in a cemetery that is the subject of a grant to a State or Tribal
Organization under 38 U.S.C. 2408. Applications for this part should be submitted to: the National Cemetery Administration, Office of the
VCGP via email to [email protected]..
Part B 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
request one through the Customer Engagement Portal (va.gov), using a digital version of the VA Form 10091 (VA-FSC Vendor File Request
Form). Please note that vendors must first register with https://www.id.me/, a simple and secure identity verification system, to use the portal.

PART A - Allowance for Privately Purchased Outer Burial Receptacles (IAW 38 C.F.R. § 38.629(d)(2))
1. APPLICANT NAME

2. ADDRESS

3. PHONE NUMBER

4. EMAIL ADDRESS

5. NAME OF DECEASED

6. DATE OF INTERMENT

7. NAME OF CEMETERY WHERE INTERRED

8. STATION ID

9. BURIAL SITE ID

CERTIFICATION

By signing below I certify that I paid for the outer burial receptacle used for the burial identified above and am attaching proof of purchase to this
application.
10. SIGNATURE OF APPLICANT (Ink signature)

11. DATE

By signing below I certify a privately purchased outer burial receptacle was used for the interment identified above.
12. SIGNATURE OF CEMETERY OFFICIAL (Ink signature)

13. DATE

14. TYPE OR PRINTED NAME OF CEMETERY OFFICIAL

15. TITLE

16. PHONE

17. EMAIL

VA FORM
MAR 2024

40-10232

PART B - Monetary Allowance for Outer Burial Receptacles Placed at Time of Interment
(IAW 38 C.F.R. § 38.629(e))
1. STATE AGENCY OR TRIBAL ORGANIZATION

2. FEDERAL ACQUISITION ID

3. VENDOR ID

4. PERIOD OF REQUEST
YEAR

QUARTER

JAN - MAR

APR - JUN

JUL - SEP

OCT - DEC

For each cemetery below, attach a list showing the gravesite location identifier and date of interment for each outer burial receptacle used at time
of interment for the period indicated above. Also, for each cemetery below, provide a gravesite layout map where gravesite locations can be
identified using the gravesite location identifier.
5a. CEMETERY NAME

b. STATION ID

c. QUANTITY USED

d. OBR ALLOWANCE
AMOUNT

e. AMOUNT CLAIMED

TOTAL

By signing below, I certify the following:
1. This request for payment includes only casketed interments where an outer burial receptacle was placed at the time of interment.
2. Outer burial receptacles used were paid for by the State or Tribal Organization requesting payment.
3. No fees for such outer burial receptacle were charged to the decedent's family or other responsible party.
6. SIGNATURE OF AUTHORIZED STATE OR TRIBAL OFFICIAL (Ink signature)

7. DATE

8. TYPE OR PRINTED NAME OF STATE OR TRIBAL CEMETERY OFFICIAL

9. TITLE

10. PHONE

11. EMAIL

VA FORM 40-10232, FEB 2024, Page 2