Form VA Form 21-530a VA Form 21-530a State Application For Interment Allowance Under 38 U.S.C

OMB Control No. 2900-0565
Respondent Burden: 30 minutes

STATE APPLICATION FOR INTERMENT ALLOWANCE UNDER 38 U.S.C. CHAPTER 23
Privacy Act Notice: 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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as
identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your
obligation to respond is required to obtain or retain benefits. Giving us the veterans' SSN account information is mandatory. Applicants are required to provide veterans' SSN under Title 38 U.S.C.
5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1,
1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential
(38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine eligibility for an interment allowance (38 U.S.C. 2303 and 2304). Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
1. NAME OF STATE

NAME OF VETERAN
(First, middle, last)

VA FILE NO.
(C/CSS)

SOCIAL
SECURITY
NUMBER

4. CLAIM FOR MONTH ENDING

3. RECIPIENT ORGANIZATION (Full name and address of payee)

2. PLACE OF BURIAL (LOCATION OF CEMETERY)

5. INTERRED VETERANS INFORMATION
SERVICE NUMBER BRANCH OF
SERVICE

SERVICE DATES
FROM

TO

DATE OF
BIRTH

DATE OF
DEATH

BURIAL DATE

I HEREBY CERTIFY THAT the above veterans were buried in a State-owned veterans cemetery (without charge) and are entitled to burial benefits under the provisions of Title 38, U.S.C.
7. DATE SIGNED

6. SIGNATURE AND TITLE OF STATE OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS

FOR VA USE ONLY

TOTAL NUMBER OF CLAIMS APPROVED

TOTAL AMOUNT APPROVED

X $300 = $
SIGNATURE OF VA APPROVING OFFICIAL
VA FORM
FEB 2012

21-530a

0.00

DATE

EXISTING STOCKS OF VA FORM 21-530a, AUG 2005, WILL BE USED.

DATE

PAGE

OF