Va Form 21 530 – Fill Out and Use

c. VETERAN'S ESTATE - If the expenses were paid from the veteran's estate, the claim should be filed by the executor/ administrator by completing Parts I, II, and IV. Submit a copy of the letters of administration or letters testamentary certified over the signature and seal of the appointing court.

d. STATE - If a veteran whose death is non service-connected was buried without charge for plot or interment in a State-owned cemetery or section used for persons eligible in a national cemetery, the claim may be filed by the State official completing Parts I, III (Items 23 and 24), and IV.

3.TIME LIMIT FOR FILING A CLAIM - A claim for non service-connected burial expenses or plot allowance must be filed with VA within 2 years from 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 from the date of correction. The

2-year limitation does not apply to service-connected burial benefits, transportation expenses or reimbursement of headstone expenses.

4.COMPLETING CLAIM BY A FIRM OR STATE AGENCY - The claim must be executed in the full name of the firm or

State agency, and show the official position or connection of the individual who signs on its behalf.

5.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 proof has previously been furnished VA, it need not be submitted again.

6.STATEMENT OF ACCOUNT MUST ACCOMPANY CLAIM

a.FUNERAL DIRECTOR - A statement of account on the funeral director's letterhead must show the name of the veteran; the nature and cost of services, including any payments made to another funeral home (show name and address); all credits; and the name of the person or persons by whom payment in whole or in part was made.

b.TRANSPORTATION - If transported by common carrier, a receipt must accompany the claim. All receipts for transportation charges should show the name of the veteran, the name of the person who paid and the amount of the charges. The itemized statement of account should show the charges made for transportation. Failure to itemize charges may result in delay or payment of a lesser amount.

c.ACCOUNT PAID IN FULL - The statement of account should be receipted in the name of the firm or individual performing the services. Bills or receipts filed in support of this claim become a part of the permanent record and will not be returned, unless specifically requested.

d.PLOT ALLOWANCE ONLY - In a claim for the plot allowance only, the statement of account must show the cost of the veteran's individual grave site, the mausoleum vault, or the columbarium niche.

7.BURIAL ASSOCIATION OR BURIAL INSURANCE - If the veteran was a member of a burial association or if any insurance company is obligated to pay all or part of the burial expenses, Item 22 should be answered "Yes." It will be necessary to support the claim with a statement from the association or insurance company setting forth the terms of the contract and how and with whom settlement was made.

8.SERVICE RECORD - The original or certified copy of the veteran's service separation document (DD214 or equivalent) which contains information as to the length, time, and character of service will permit prompt processing.

9.TOLL-FREE TELEPHONE ASSISTANCE - You can call us toll-free within the U.S. by dialing 1-800-827-1000. If you are located in the local dialing area of a VA regional office, you can also call us by checking your local telephone directory. For the hearing impaired, our TDD number is 1-800-829-4833.

10.WHERE DO I MAIL MY COMPLETED APPLICATION? - You should mail your application to the VA regional office located in your state. You can obtain the mailing address for VA regional offices by accessing the VA Internet web site at www.va.gov/ directory. The address is also located in the government pages of your telephone book under "United States Government, Veterans."

OMB Approved No. 2900-0003 Respondent Burden: 22 minutes

6A. MAILING ADDRESS OF CLAIMANT (Number and street or rural route, city or P.O., State and ZIP Code)

6B. IF CLAIMANT IS A FUNERAL HOME PROVIDE THE EMPLOYER IDENTIFICATION NUMBER (EIN)

PART I - INFORMATION REGARDING VETERAN

8D. WHERE DID THE VETERAN'S DEATH OCCUR? (Check one)

SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)

PART II - CLAIM FOR BURIAL BENEFITS AND/OR INTERMENT ALLOWANCE IF PAID BY CLAIMANT

NOTE - If claiming Plot Allowance Only, do not complete Part II, but complete Parts III and IV on page 4.

I CERTIFY THAT the foregoing statements made in connection with this application on account of the named veteran are true and correct to the best of my knowledge and belief.

NOTE - Where the claimant is a firm or other unpaid creditor, Items 32A thru 35 MUST be completed by the individual who authorized services.

I CERTIFY THAT the foregoing statements made by the claimant are correct to the best of my knowledge and belief.

WITNESS TO SIGNATURE IF MADE BY "X"

NOTE - If claimant signed above using an "X", signature must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and addresses of such witnesses must be shown below.

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 include any veteran with an other than dishonorable discharge who dies after service or any serviceman or servicewoman 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 request from the family.

For additional information on burial benefits go to the web site, www.cem.va.gov/bbene_burial.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 to www.va. gov/directory.