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OMB NUMBER: 2900-0784 |
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EXPIRATION DATE: Apr. 30, 2023 |
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RESPONDENT BURDEN: 20 minutes |
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APPLICATION FOR PRE-NEED DETERMINATION OF |
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ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY |
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NOTE: Please read information on reverse before |
Submit Application and Supporting Documentation to VA by: |
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completing this form. If additional space is required, |
Mail: to National Cemetery Scheduling Office, P.O. Box 510543, St. Louis, MO 63151; or |
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attach a separate sheet of paper. |
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Fax: to the National Cemetery Scheduling Office at (855) 840-8299 |
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IMPORTANT: Pre-Need means before death. Only complete this form if you are applying for a Pre-Need determination of eligibility for burial in a VA national cemetery. Time of Need means time of death. DO NOT complete this form if the individual is already deceased; instead, contact a local funeral home or the National Cemetery Scheduling Office at 1-800-535-1117 to expedite processing.
*REQUIRED ITEMS: YOU MUST COMPLETE THOSE ITEMS IDENTIFIED WITH AN ASTERISK (*)
SECTION I - VETERAN/SERVICEMEMBER
(Claims for eligibility for burial are based upon the Veterans/Servicemember's military service)
*1. VETERAN/SERVICEMEMBER NAME
(Include Suffix) (Last, First, Middle Name or Initial)
*2. NAME USED DURING MILITARY SERVICE (Include Suffix) (If different than Item 1) (Last, First, Middle Name)
3.MAILING ADDRESS (Street, City, State, and ZIP Code P.O. Box, Rural Route, etc.)
*4. SOCIAL SECURITY NUMBER
5.MILITARY SERVICE NUMBER (If different from SSN)
6.VA CLAIM NUMBER (If known)
*7. SEX (Information will be used for |
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*8. RACE/ETHNICITY (Select one or more) (Information will be used for statistical purposes only) |
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statistical purposes only) |
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AMERICAN INDIAN OR |
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ASIAN |
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BLACK OR AFRICAN |
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HISPANIC OR |
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NOT HISPANIC |
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NATIVE HAWAIIAN OR |
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WHITE |
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MALE |
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FEMALE |
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ALASKA NATIVE |
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AMERICAN |
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LATINO |
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OR LATINO |
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OTHER PACIFIC ISLANDER |
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9. DATE OF BIRTH (MM/DD/YYYY) |
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10. PLACE OF BIRTH (City, State or Territory) |
*11. IS VETERAN/SERVICEMEMBER |
12. DATE OF DEATH |
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DECEASED? |
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(If applicable) (MM/DD/YYYY) |
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YES |
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NO |
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DON'T KNOW |
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*13. MARITAL STATUS
SINGLE SEPARATED MARRIED
*14. MILITARY STATUS USED TO APPLY FOR ELIGIBILITY DETERMINATION (Check all that apply)
A. VETERAN |
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B. RETIRED ACTIVE DUTY |
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C. DIED ON ACTIVE DUTY |
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D. RETIRED RESERVE |
E. RETIRED NATIONAL GUARD F. DEATH RELATED TO INACTIVE DUTY TRAINING G. OTHER (See instructions)
MILITARY SERVICE DATA
*15. BRANCH OF SERVICE |
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16. DATE OF ENTRY |
17. DATE OF |
18. DISCHARGE - CHARACTER |
19. HIGHEST RANK ATTAINED |
20. STATE (Abbrev.) |
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DISCHARGE |
OF SERVICE (See instructions) |
(No pay grades) |
(National Guard |
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Service Only) |
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21. IS THERE ANYONE CURRENTLY BURIED IN A VA NATIONAL CEMETERY |
22. NAME OF DECEDENT(S) AND VA NATIONAL CEMETERY WHERE BURIED |
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UNDER THIS VETERAN'S/SERVICEMEMBER'S ELIGIBILITY? |
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YES (Complete Item 22) |
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NO (Skip Item 22 |
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DON'T KNOW (Skip Item 22) |
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23. SUPPORTING DOCUMENTS ATTACHED |
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YES |
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NO (See instructions for information on recommended documentation.) |
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SECTION II - CLAIMANT INFORMATION
(Information about the individual for whom determination for eligibility for burial in a VA National Cemetery is requested)
*24. CLAIMANT (See instructions) (***Each Claimant requires a separate VA Form 40-10007)
(Name) LastFirstMiddle
WHO IS (check one):
A. THE VETERAN/SERVICEMEMBER NAMED IN ITEM 1
B. THE SPOUSE/SURVIVING SPOUSE OF THE VETERAN/SERVICEMEMBER IN ITEM 1 C. AN UNMARRIED ADULT CHILD OF THE VETERAN/SERVICEMEMBER IN ITEM 1
Additional documentation required. Please read instructions on reverse carefully if selecting 24C.
D. OTHER (Please specify)
*25. CLAIMANT'S MAILING ADDRESS (Street, City, State, and ZIP Code, P.O. Box, Rural Route, etc.) (If different from item 3)
26. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
*27. CLAIMANT'S SOCIAL SECURITY NUMBER (If different from item 4)
*28. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY ) (If different from item 9)
*29. CLAIMANT'S MAIDEN NAME (If applicable)
30. DESIRED VA NATIONAL OR STATE/TRIBAL CEMETERY (Optional - See instructions)
31.EMAIL ADDRESS (Optional - See instructions)
SECTION III - CERTIFICATION AND SIGNATURE
CERTIFICATION: By signing below, I certify that I am the Claimant identified in item 24, or an individual signing for the Claimant identified in Item 35. All of the information entered on this form about the Claimant is true and correct to the best of my knowledge. A fraudulent statement that leads to burial in a national cemetery or receiving other benefits from the VA could result in disinterment from that national cemetery and other penalties in accordance with the law. I acknowledge that otherwise eligible individuals may be barred from burial for committing certain serious crimes, as provided under 38 U.S.C. § 2411. VA will therefore validate a previous determination of eligibility at the time of need to check for those bars in addition to law changes or Claimant status changes that may affect eligibility of the Claimant.
*34. YOUR RELATIONSHIP TO THE CLAIMANT IN ITEM 24 (Check one; See instructions)
A. SELF (Stop here. Leave Items 35-38 blank)
B. INDIVIDUAL SIGNING FOR THE CLAIMANT who is under 18 years of age, is mentally incompetent, or is physically unable to sign the pre-need application
(Complete items 35 through 38)
*35. NAME OF INDIVIDUAL FROM ITEM 34B COMPLETING FOR THE CLAIMANT
(Last, First, Middle Name)
*36. MAILING ADDRESS OF INDIVIDUAL COMPLETING THIS FORM FOR THE CLAIMANT (Street, City, State, and Zip Code, P.O. Box, Rural Route, etc.)
*37. TELEPHONE NUMBER (Include Area Code) (Optional)
38. EMAIL ADDRESS (Optional)
VA FORM 40-10007
MAY 2020
INSTRUCTIONS FOR COMPLETING VA FORM 40-10007 APPLICATION FOR PRE-NEED DETERMINATION OF ELIGIBILITY
FOR BURIAL IN A VA NATIONAL CEMETERY
For more complete information on eligibility requirements for burial in a VA national cemetery, visit the National Cemetery Administration online at http://www.cem.va.gov/cem/burial_benefits/eligible.asp or call the National Cemetery Scheduling Office at 1-800-535-1117. For the purposes of this form, the term burial includes inurnment (above ground remains placement in a columbarium) and scattering of ashes, (if the cemetery chosen offers those options). A Pre-Need determination of eligibility does not guarantee burial in a specific VA national cemetery. Burial in a specific VA national cemetery will be scheduled at the Time of Need. The equivalent of this form can be completed online at https://www.va.gov/burials-and- memorials/pre-need/form-10007-apply-for-eligibility/introduction. In order to assist in completing this form, specific instructions and explanations for certain items are given below.
SECTION I: VETERAN/SERVICEMEMBER
Eligibility for burial in a VA national cemetery is based on the qualifying service of a Veteran/Servicemember. This section of the form is used to determine if qualifying service exists. Not all items are mandatory; however, answers to questions will aid VA in searching for records in archives to support the claim.
Item 14 Military status used to apply for eligibility determination: For VA benefit purposes, a Veteran is a person who served in the active military, naval, or air service, and who was discharged under conditions other than dishonorable. VA will determine on a case-by-case basis whether certain Reserve duty qualifies. If eligibility derives from a status not listed, or if the individual is not certain of the status, check “Other” and submit evidence of service and VA will provide appropriate assistance. Servicemembers who die on active duty are eligible for burial. If you are arranging burial for an active duty Servicemember or his or her dependents, you should contact a local funeral home or the National Cemetery Scheduling Office at 1-800-535-1117 to expedite processing.
Item 18 Discharge - Character of Service: Please indicate one type of “Discharge - Character of Service”: Honorable; General; Entry Level Separation/Uncharacterized; Other Than Honorable; Bad Conduct; or Dishonorable. If uncertain of the type of discharge or character of service, indicate “Other” and include available supporting documents.
Item 23 Supporting military service documents: VA recommends that you attach photocopies of readily available supporting documents so that we can make the determination quickly. Documents may include the most recent discharge document (DD Form 214) showing the highest rank and valor awards and decorations, active duty service records other than for training purposes, or active duty for a minimum of 24 continuous months for enlisted Servicemembers after September 7, 1980; for officers, after October 16, 1981, or the full period for which the person was called to active duty. If you are unable to locate copies of military records, apply anyway, as VA will attempt to obtain records necessary to make a determination.
SECTION II: CLAIMANT INFORMATION
Item 24 Each Claimant requires a separate VA Form 40-10007.
24b. Spouse means a person who is or was legally married to a Veteran. Surviving Spouse mean a person who was legally married to a Veteran at the time of the Veteran's death and includes a surviving spouse who had a subsequent remarriage. A non-Veteran spouse of a Veteran whose marriage to the Veteran was dissolved by divorce or annulment issued by an authoritative court is not eligible for burial in a VA national cemetery.
24c. An unmarried adult child of the Veteran is an individual who became permanently physically or mentally disabled and incapable of self-support before reaching 21 years of age, or before reaching 23 years of age if pursuing a full-time course of instruction at an approved educational institution. Before VA can approve a claim for an unmarried adult child, we will require statements from both the Veteran, spouse of the Veteran, and/or authorized representative AND the current attending physician (on physician's letterhead) stating the nature of the disability, date of onset of the disability, degree of dependency on the Veteran or Veteran's family, and the marital status of the child. Please provide photocopies of these statements with the application. Note: Minor children of eligible Veterans are eligible for burial in a VA national cemetery. The minor child of an eligible Veteran is a child who is unmarried and who is under 21 years of age; or who is under 23 years of age and is pursuing a full-time course of instruction at an approved educational institution.
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24d. Please explain your Claimant status or relationship to the Veteran/Servicemember. |
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A list of VA national cemeteries is available online at http://www.cem.va.gov/cem/cems/allnational.asp A favorable Pre-Need |
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determination of eligibility does not guarantee burial in a specific national cemetery. Burial in a specific VA national cemetery will |
31be scheduled at the time of need. If you provide an email address, VA may use your email address to communicate with you about your claim and burial benefits.
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SECTION III: CERTIFICATION AND SIGNATURE |
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Items 32 |
The pre-need application must be signed (Item 32) and dated (Item 33) for VA to process. |
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and 33 |
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Item 34 |
You must indicate your relationship to the claimant in Item 34. |
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34a. Check (A) if you are the claimant |
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34b. Check (B) and complete Items 35-38 if your are signing for a claimant who has not attained the age of 18 years, is mentally incompetent, or is physically unable to sign the pre-need application. You may be a court-appointed representative, a person who is responsible for the care of the individual (including a spouse or other relative), or an attorney in fact or agent authorized to act on behalf of the claimant under a durable power or attorney. If the claimant is in the care of an institution, a manager or principal officer of the institution may sign the form. Please attach supporting documents or an affidavit establishing your position relative to the claimant.
Privacy Act Information: Title 38 U.S.C. 2402 authorizes the solicitation of this information. 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, 175VA41A, published in the Federal Register. VA considers the requested information relevant and necessary to determine maximum benefits under the law. The purpose for which the records are used will include, but will not be limited to the provision of VA burial and memorial benefits; provision of information about VA burial and memorial benefits, including specific claims; determination of eligibility for burial in a VA national cemetery; disclosure of military service information upon request from VA funded State and Tribal Veterans cemeteries; coordination of committal services and interment upon request of families, funeral homes, and others of eligible decedents at VA national cemeteries.
Respondent Burden: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate the time expended by individuals who complete this form will average 20 minutes per response, including the time to review instructions, search existing data sources, gather the necessary data, and complete and review the collection of information. Your response is voluntary and not required to obtain or retain benefits to which you may be entitled. Send comments concerning the accuracy of this burden estimate, including suggestion for reducing this burden or any other aspect of this collection of information to the VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. Please DO NOT send claims for, or correspondence regarding benefits to this address.
REVERSE OF VA FORM 40-10007, MAY 2020
