Revised Form

GENERAL INFORMATION SHEET
APPLICATION FOR STANDARD GOVERNMENT HEADSTONE OR MARKER
FOR INSTALLATION IN A PRIVATE CEMETERY OR A STATE VETERANS' CEMETERY
RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average one-fourth hour 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. 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 (005E3), 810 Vermont Avenue, NW, Washington, DC 20420. Please DO NOT send applications for benefits to this
address.

BENEFIT PROVIDED
a. HEADSTONE OR MARKER
For deaths occurring on or after September 11, 2001 - Furnished upon application for the grave of any eligible deceased veteran. Will be
provided regardless of whether or not the grave is already marked with a privately purchased headstone or marker. Applicant may be anyone
having knowledge of the deceased.
For deaths occurring before September 11, 2001 - Furnished upon application for the UNMARKED GRAVE of any eligible deceased
veteran. The individual must certify the grave is unmarked and a Government headstone or marker is preferred to a privately purchased
headstone or marker. A grave is considered marked if a monument displays the decedent's name and date of birth and/or death, even
though the veteran's military data is not shown. Applicant may be anyone having knowledge of the deceased.
b. MEMORIAL HEADSTONE OR MARKER - Furnished upon application for installation in a cemetery only to commemorate any eligible
veteran whose remains have not been recovered or identified, were buried at sea, donated to science, or cremated and the remains scattered; may
not be used as a memento. Check box in block 28 and explain in block 27. Applicant may be anyone having knowledge of the deceased.
WHO IS ELIGIBLE - Any deceased veteran discharged under conditions other than dishonorable. A copy of the deceased veteran's discharge certificate
(DD Form 214 or equivalent) or a copy of other official document(s) establishing military service must be attached. Do not send original documents; they
will not be returned. 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; a copy of the Reserve Retirement
Eligibility Benefits Letter must accompany the application. Reservists called to active duty and National Guard members who are Federalized and who
serve for the period called are eligible. Service prior to World War I requires detailed documentation, e.g., muster rolls, extracts from State files, military or
State organization where served, pension or land warrant, etc.
HOW TO APPLY
FAX applications and supporting documents to 1-800-455-7143.
IMPORTANT: If faxing more than one application - fax each
application package (application plus supporting documents) individually i.e.,
disconnect the call and redial for each submission.

MAIL applications to: Memorial Programs Service (41A1)
Department of Veterans Affairs
5109 Russell Road
Quantico, VA 22134-3903

A Government headstone or marker may be furnished only upon receipt of a fully completed and signed application with required supporting
documentation.
SIGNATURES REQUIRED - The person responsible for the information on this form signs in block 17; the person agreeing to accept delivery
(consignee) in block 22, and the cemetery or other responsible official in block 24. If there is no official on duty at the cemetery, the signature of the person
responsible for the property listed in block 21 is required. Entries of "None," "Not Applicable," or "NA" cannot be accepted. State Veterans' Cemeteries are
not required to complete blocks 17, 18, 22 and 23.
ASSISTANCE NEEDED - If assistance is needed to complete this application, 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 application. Use block 27 for any clarification or other information
you wish to provide. Should you have questions when filling out this form, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or
via e-mail at mps.headstones@va.gov For more information regarding headstones and markers visit our website at www.cem.va.gov.
INSTALLATION - The Government is not responsible for costs to install the headstone or marker in private cemeteries.
TRANSPORTATION AND DELIVERY OF MARKER - The headstone or marker is shipped without charge to the consignee designated in block 19 of
the application. The delivery will not be made to a Post Office box. The consignee should be a business with full delivery address and telephone number.
If the consignee is not a business explain fully in block 27. For delivery to a Rural Route address, you must include a daytime telephone number including
area code in block 20. If you fail to include the required address and telephone number information, we cannot deliver the marker.
CAUTION - To avoid delays in the production and delivery of the headstone or marker, please check carefully to be sure you have accurately furnished all
required information before faxing or mailing the application. Mistakes cannot be corrected after a headstone or marker has been ordered. Headstones or
markers furnished remain the property of the United States Government and may not be used for any purpose other than to honor the memory of the
decedent for whom the headstone or marker is issued.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
AUG 2007

40-1330

Adobe Designer

ILLUSTRATIONS OF STANDARD GOVERNMENT HEADSTONES AND MARKERS
UPRIGHT HEADSTONE
WHITE MARBLE OR
LIGHT GRAY GRANITE

FLAT MARKERS

BRONZE NICHE

This niche marker is 8-1/2 inches long,
5-1/2 inches wide, with 7/16 inch rise.
Weight is approximately 3 pounds;
mounting bolts and washers are
furnished with the marker. For use if
entombment is in a columbarium or
mausoleum, or to supplement a private
monument, for deaths occurring on or
after September 11, 2001.

This headstone is 42 inches long, 13 inches wide
and 4 inches thick. Weight is approximately 230
pounds. Variations may occur in stone color, and
the marble may contain light to moderate veining.

BRONZE

This grave marker is 24 inches long, 12 inches wide, with 3/4 inch
rise. Weight is approximately 18 pounds. Anchor bolts, nuts and
washers for fastening to a base are furnished with the marker. The
base is not furnished by the Government.
LIGHT GRAY GRANITE OR WHITE MARBLE

This grave marker is 24 inches long, 12 inches wide, and 4 inches
thick. Weight is approximately 130 pounds. Variations may occur
in stone color; the marble may contain light to moderate veining.

NOTE: Civil War Era headstones - In addition to the headstone and markers pictured, two special styles of upright headstones are available for those who
served with Union Forces during the Civil War or for those who served in the Spanish-American War, and another for those who served with the
Confederate States of America during the Civil War. Requests for these special styles should be made in block 27 of the application. It is necessary to
submit detailed documentation that supports eligibility.

INSCRIPTION INFORMATION
MANDATORY ITEMS of inscription at Government expense are: Legal Name, Branch of Service, Year of Birth, and Year of Death. Branches of

Service are: U.S. Army (USA), U.S. Navy (USN), U.S. Air Force (USAF), U.S. Marine Corps (USMC), U.S. Coast Guard (USCG), and by exception, U.S.
Army Air Forces (USAAF), and other parent organizations authorized for certain periods of time and special units such as Women's Army Auxiliary Corps
(WAAC), Women's Air Force Service Pilots (WASP), U.S. Public Health Service (USPHS), and National Oceanic & Atmospheric Administration (NOAA).
Different examples of inscription formats are illustrated above. More than one branch of service is permitted, subject to space availability.

OPTIONAL ITEMS are identified on the application in boxes with bold outlines. These items may be included at Government expense if desired.

Optional items include month and day of birth in block 5A, month and day of death in block 5B, highest rank attained in block 7, awards in block 9, war
service in block 10, and emblem of belief in block 12. War service includes active duty service during a recognized period of war and the individual does
not have to serve in the actual place of war, i.e. Vietnam may be inscribed if the veteran served during the Vietnam War period, even though the individual
never served in Vietnam itself. Supporting documentation must be included with the application if you wish to include the highest rank and/or awards.

RESERVED SPACE for future inscriptions at private expense, such as spousal or dependent data, is allowed if requested in block 27 and if space is
available. Only two lines of space may be reserved on flat markers due to space limitations. Reserved space is unnecessary on upright marble or granite
headstones as the reverse side is available for future inscriptions.
MEMORIAL HEADSTONES AND MARKERS (remains are not buried). The words "In Memory Of" are mandatory and precede the authorized
inscription data. The words "In Memory Of" are not inscribed when remains are buried.

ADDITIONAL ITEMS may be inscribed at government expense if they are requested on the initial application and space is available. Examples of

acceptable items include terms of endearment, nicknames (in expressions such as "OUR BELOVED POPPY"), military or civilian credentials or
accomplishments such as DOCTOR, REVEREND, etc., and special unit designations such as WOMEN'S ARMY CORPS, ARMY AIR CORPS, ARMY
NURSE CORPS or SEABEES. All requests for additional inscription items should be stated in block 27, and are subject to VA approval. No graphics,
emblems or pictures are permitted except VA approved emblems of belief, the Medal of Honor, and the Southern Cross of Honor for Civil War Confederate
Veterans.
INCOMPLETE OR INACCURATE INFORMATION ON THE APPLICATION MAY RESULT IN ITS RETURN TO THE APPLICANT, A DELAY IN RECEIPT
OF THE HEADSTONE OR MARKER, OR AN INCORRECT INSCRIPTION.

Form approved, OMB No. 2900-0222
Respondent Burden: 15 minutes

IMPORTANT: Please read the General Information Sheet before completing this form. Type or
print clearly all information except for signatures. Illegible printing could result in an incorrect
headstone or marker or delivery. Blocks outlined in bold are optional inscription items. Unless
indicated otherwise all other blocks must be completed. MILITARY DISCHARGE DOCUMENTS
OR RELATED SERVICE INFORMATION IS REQUIRED.

1. TYPE OF REQUEST
INITIAL (First time) REQUEST
SECOND REQUEST
CORRECTED APPLICATION OR REPLACEMENT

2. NAME OF DECEASED TO BE INSCRIBED ON HEADSTONE OR MARKER (NO NICKNAMES OR TITLES PERMITTED)
FIRST (Or Initial)

MIDDLE (Or Initial)

LAST

3. GRAVE IS:

SUFFIX

CURRENTLY MARKED
(with privately purchased marker)
NOT MARKED

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
PERIODS OF ACTIVE MILITARY DUTY (For additional space use Block 27)

4. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO. (Failure to complete
will delay processing.)
SSN:

6A. DATE(S) ENTERED

OR SVC. NO.:

5A. DATE OF BIRTH
MONTH

DAY

DAY

MONTH

6B. DATE(S) SEPARATED
YEAR

MONTH

YEAR

MONTH

DAY

9. VALOR OR PURPLE HEART AWARD(S) (Documentation must be provided)
BRONZE
MEDAL OF DST SVC NAVY
AIR FORCE SILVER STAR
PURPLE
MEDAL
HONOR
CROSS
CROSS CROSS
STAR
HEART

B

G

UPRIGHT
MARBLE
U

FLAT
MARBLE

BRONZE
NICHE

F

WORLD
KOREA
WAR II

VIETNAM

PERSIAN
GULF

OTHER
(Specify)

12. DESIRED EMBLEM OF BELIEF
UPRIGHT
GRANITE

Z

13A. NAME AND MAILING ADDRESS (No., Street, City, State, and
ZIP Code) OF PERSON TO CONTACT FOR ADDITIONAL
INFORMATION

OTHER
(Specify)

10. WAR SERVICE (Check applicable box(es))
OTHER
(Specify)

11. TYPE OF HEADSTONE OR MARKER REQUESTED (Check one)
FLAT
GRANITE

YEAR

YEAR

7. HIGHEST RANK ATTAINED (No pay grades) 8. BRANCH OF SERVICE (Check applicable box(es) - must be consistent with rank in Box 7)
MARINE
COAST
ARMY
MERCHANT
ARMY
NAVY
AIR FORCE
CORPS
GUARD
AIR FORCES
MARINE

FLAT
BRONZE

DAY

5B. DATE OF DEATH

NONE

EMBLEM NUMBER
(Specify)(See reverse side of this form for authorized emblems)
__________

V

13B. DAYTIME PHONE NO. OF PERSON TO CONTACT
FOR ADDITIONAL INFORMATION

16. ARE YOU:
NEXT OF KIN

14. E-MAIL ADDRESS (Optional)

FUNERAL
DIRECTOR

15. FAX NO. (Optional)

OTHER (Specify)

VETERANS
SERVICE
OFFICER
CEMETERY
OFFICIAL

CERTIFICATION: By signing below I certify the headstone or marker will be installed in the cemetery listed in block 21 at no expense to the
Government and all information entered on this form is true and correct to the best of my knowledge.
18. DATE (MM/DD/YYYY)

17. SIGNATURE OF PERSON WHOSE NAME APPEARS IN BLOCK 13A

19. NAME AND DELIVERY ADDRESS OF BUSINESS (CONSIGNEE) THAT WILL
ACCEPT PREPAID DELIVERY (No., Street, City, State and ZIP Code); P.O. BOX
IS NOT ACCEPTABLE

20. DAYTIME PHONE NO.
(Include Area Code)

21. NAME AND ADDRESS OF CEMETERY WHERE
GRAVE IS LOCATED (No., Street, City, State and
ZIP Code)

CERTIFICATION: By signing below I agree to accept prepaid delivery of the headstone or marker.
23. DATE (MM/DD/YYYY)

22. PRINTED NAME AND SIGNATURE OF PERSON REPRESENTING BUSINESS (CONSIGNEE) NAMED IN BLOCK 19

CERTIFICATION: By signing below I certify the type of headstone or marker checked in block 11 is permitted in the cemetery named in block 21.
24. PRINTED NAME AND SIGNATURE OF CEMETERY OR OTHER RESPONSIBLE 25. DAYTIME PHONE NO. (Include Area Code)
OFFICIAL
27. REMARKS (Optional inscription space will vary in size according to the type of marker)

26. DATE (MM/DD/YYYY)

28. CHECK BOX BELOW IF REMAINS ARE
NOT BURIED AND EXPLAIN IN
BLOCK 27 (e.g., lost at sea, remains
scattered, etc.)
REMAINS NOT BURIED

STATE VETERANS' CEMETERY AND GRAVE LOCATION (Cemetery Use Only)
29. ID CODE
VA FORM
AUG 2007

40-1330

30. SECTION

31. GRAVE NO.

APPLICATION FOR STANDARD GOVERNMENT HEADSTONE OR MARKER

AUTHORIZED EMBLEMS (See block 12)
The graphics shown below are of the 20 most requested emblems of belief for placement on government-furnished headstones/markers.
The listing below shows all emblems that may be requested.

EMBLEMS OF BELIEF AVAILABLE:
CHRISTIAN CROSS (01)
BUDDHIST (Wheel of Righteousness) (02)
HEBREW (Star of David) (03)
PRESBYTERIAN CROSS (04)
RUSSIAN ORTHODOX CROSS (05)
LUTHERAN CROSS (06)
EPISCOPAL CROSS (07)
UNITARIAN CHURCH (Flaming Chalice) (08)
UNITED METHODIST CHURCH (09)
AARONIC ORDER CHURCH (10)
MORMON (Angel Moroni) (11)
NATIVE AMERICAN CHURCH OF NORTH AMERICA (12)
SERBIAN ORTHODOX (13)
GREEK CROSS (14)
BAHAI (9 Pointed Star) (15)
ATHEIST (16)
MUSLIM (Crescent and Star) (17)
HINDU (18)
KONKO-KYO FAITH (19)
WICCA (Pentacle)

COMMUNITY OF CHRIST (20)
SUFISM REORIENTED (21)
TENRIKYO CHURCH (22)
SIECHO-NO-IE (23)
THE CHURCH OF WORLD MESSIANITY (lzunome) (24)
UNITED CHURCH OF RELIGIOUS SCIENCE (25)
CHRISTIAN REFORMED CHURCH (26)
UNITED MORAVIAN CHURCH (27)
ECKANKAR (28)
CHRISTIAN CHURCH (29)
CHRISTIAN & MISSIONARY ALLIANCE (30)
UNITED CHURCH OF CHRIST (31)
HUMANIST EMBLEM OF SPIRIT (32)
PRESBYTERIAN CHURCH (USA) (33)
IZUMO TAISHAKYO MISSION OF HAWAII (34)
SOKA GAKKAI INTERNATIONAL - USA (35)
SIKH (KHANDA) (36)
CHRISTIAN SCIENCE (Cross & Crown) (97)
MUSLIM (Islamic 5 Pointed Star) (98)

This application form is normally updated every two years. To obtain the most recent information about headstones and markers
including the complete and most current list of available emblems of belief (listing all names and graphics), please visit our website at
www.cem.va.gov. You may also request a copy of this list by contacting our Applicant Assistance unit toll free at 1-800-697-6947, or
via e-mail at: mps.headstones@va.gov .
VA FORM 40-1330, AUG 2007