Form VA Form 21P-530a VA Form 21P-530a State or Tribal Organization Application for Interment A

OMB Control No. 2900-0565
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

STATE OR TRIBAL ORGANIZATION APPLICATION FOR INTERMENT ALLOWANCE
(UNDER 38 U.S.C. CHAPTER 23)
INSTRUCTIONS: Please read the Privacy Act and Respondent Burden information on Page 2 before completing this form.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly and legibly to help process the form.
1. NAME OF DECEASED VETERAN (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VETERAN'S SERVICE NUMBER (If different
from Item 2)

5. VETERAN'S DATE OF BIRTH

6. VETERAN'S PLACE OF BIRTH
(City and State)

Day

Month

Year

4. VETERAN'S FILE NUMBER

7. VETERAN'S DATE OF DEATH
Month

Day

Year

SECTION II: VETERAN'S ACTIVE DUTY SERVICE
SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)
8B. ENTERED SERVICE

8A. BRANCH OF SERVICE

PLACE ENTERED ACTIVE SERVICE

DATE ENTERED ACTIVE SERVICE

9A. GRADE, RANK OR RATING WHEN SEPARATED
FROM SERVICE

9B. SEPARATED FROM SERVICE
PLACE LEFT ACTIVE SERVICE

DATE LEFT ACTIVE SERVICE

10. IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME:

SECTION III: STATE CEMETERY OR TRIBAL ORGANIZATION INFORMATION
11. NAME OF STATE CEMETERY OR TRIBAL
ORGANIZATION CLAIMING INTERMENT ALLOWANCE

13. DATE OF BURIAL (MM/DD/YYYY)

12. PLACE OF BURIAL
A. STATE CEMETERY OR TRIBAL CEMETERY
NAME

14. RECIPIENT ORGANIZATION NAME (Full Name of Payee)

B. STATE CEMETERY OR TRIBAL CEMETERY
LOCATION

15. RECIPIENT ORGANIZATION PHONE NUMBER
(Include Area Code)

16. RECIPIENT ORGANIZATION PAYEE ADDRESS (Number and street or rural route, P.O. Box, City, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province
VA FORM
XXX XXXX

21P-530a

City
Country

ZIP Code/Postal Code
SUPERSEDES VA FORM 21P-530a, DEC 2019,
WHICH WILL NOT BE USED.

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Veteran's Social Security No.

SECTION IV: CERTIFICATION AND SIGNATURE

I HEREBY CERTIFY THAT the veteran named in Item 1 was buried in a State-owned Veterans Cemetery or Tribal Cemetery
(without charge).
17A. SIGNATURE OF STATE OR TRIBAL OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS (Sign in ink)

17B. TITLE OF STATE OR TRIBAL OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS

17C. DATE SIGNED

SECTION V: REMARKS
18. REMARKS (If any)

Mail your completed form to:
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, Wisconsin 53547-5365
PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed
outside the Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act, including the routine uses
identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment
Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine
maximum benefits under the law and is required to obtain benefits. Information submitted is subject to verification through computer
matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine eligibility for an internment 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 5 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 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.

VA FORM 21P-530a, XXX XXXX

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