VA Form 40-1330M Claim for government Medallion for Installation in a Pri

GENERAL INFORMATION SHEET
CLAIM FOR GOVERNMENT MEDALLION FOR INSTALLATION
IN A PRIVATE 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. VA cannot conduct or sponsor a collection of information unless it has a valid OMB number. Your obligation to respond 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.

BENEFIT PROVIDED: MEDALLION
For deaths occurring on or after November 1, 1990 - Furnished upon receipt of claim for affixing to a privately purchased monument of any eligible
deceased Veteran. Eligible Veterans are entitled to a Government furnished headstone or marker, or the medallion, but not both. If requesting a headstone
or marker, please use the VA Form 40-1330. The medallion is available in three sizes: 5 inches, 3 inches, and 1-1/2 inches. Each medallion is inscribed
with the word VETERAN across the top and the Branch of Service at the bottom (See Note in Block 7 of the form for further information).

Five or Three inch Bronze Medallion

One and a half inch Bronze Medallion

DELIVERY AND INSTALLATION - The medallion is shipped without charge to the applicant designated in block 9 or the alternate in Block 14 of the
claim. The Government is not responsible for costs to affix the medallion on the privately purchased headstone or marker. Appropriate affixing adhesives,
hardware and instructions are provided with the medallion.
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.
HOW TO SUBMIT A CLAIM
FAX 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.

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

A VA medallion may be furnished only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED - The person responsible for the information on this form signs in block 13A.
ASSISTANCE NEEDED - If assistance is needed to complete this claim, 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 our program, visit our website at http://www.cem.va.gov/ . No fee should be paid
in connection with the preparation of this claim.
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. Medallions 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 deceased Veteran for whom the medallion is issued.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
MAR 2010

40-1330M

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Form approved, OMB No.
Respondent Burden: 15 minutes

CLAIM FOR GOVERNMENT MEDALLION FOR
INSTALLATION IN A PRIVATE CEMETERY

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

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 incorrect delivery
of the medallion. Unless indicated otherwise all other blocks must be completed. MILITARY
DISCHARGE DOCUMENTS OR RELATED SERVICE INFORMATION IS REQUIRED.
3. GRAVE IS:

2. NAME OF DECEASED
FIRST (Or Initial)

MIDDLE (Or Initial)

LAST

SUFFIX

CURRENTLY MARKED
(with privately purchased marker)
NOT MARKED

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
4. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO. (Failure to complete
will delay processing.)
SSN:

OR SVC. NO.:

5A. DATE OF BIRTH
MONTH

PERIODS OF ACTIVE MILITARY DUTY
6A. DATE(S) ENTERED

DAY

MONTH

DAY

6B. DATE(S) SEPARATED
YEAR

MONTH

DAY

YEAR

5B. DATE OF DEATH
YEAR

MONTH

DAY

YEAR

7. 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

COAST GUARD

MERCHANT MARINE

NAVY

AIR FORCE

ARMY AIR FORCES

OTHER (Specify)

8. MEDALLION SIZE REQUESTED (Check one)
3 INCH (M3)

5 INCH (M5)

10. DAYTIME PHONE NO. OF PERSON TO CONTACT FOR ADDITIONAL INFORMATION
1-1/2 INCH (M1)

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

11. E-MAIL ADDRESS (Optional)

12. ARE YOU:
NEXT OF KIN

CEMETERY OFFICIAL

FUNERAL DIRECTOR

OTHER (Specify)

CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in block
16 at no expense to the Government, and that I (or the party listed in block 14) has agreed to accept delivery, and all information entered on this form is
true and correct to the best of my knowledge.
13B. DATE (MM/DD/YYYY)

13A. SIGNATURE OF PERSON WHOSE NAME APPEARS IN BLOCK 9

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

15. DAYTIME PHONE NO.
(Include Area Code)

16. NAME AND ADDRESS OF CEMETERY WHERE
PRIVATELY PURCHASED HEADSTONE OR MARKER
OF THE DECEASED VETERAN IS LOCATED
(No., Street, City, State and ZIP Code)

17. WOULD YOU LIKE A PRESIDENTAL MEMORIAL CERTIFICATE (PMC) MAILED TO YOU?
(If you check "YES," please enter the number of certificates desired)
YES

VA FORM
MAR 2010

NO

40-1330M

NO. OF CERTIFICATES DESIRED

NOTE: For more information on this benefit, please visit our website at http://www.cem.va.gov/ .

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