Form 40-1330UP Claim For Commemorative Urn or Plaque For Veterans Crema

GENERAL INFORMATION SHEET
CLAIM FOR COMMEMORATIVE URN OR PLAQUE FOR
VETERANS' CREMAINS NOT INTERRED
RESPONDENT BURDEN
Public reporting burden for this collection of information is estimated to average 10 minutes 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 response (per OMB guidance) 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 claims for benefits to this address.
PRIVACY ACT
VA considers the responses you submit confidential (38 U.S.C. 5701). VA may only disclose this information outside the VA if the disclosure is authorized under the
Privacy Act, including the routine uses identified in the VA system of records, 48VA40B, published in the Federal Register. VA considers the requested information
relevant and necessary to determine maximum benefits under the law.
BENEFIT PROVIDED
a. COMMEMORATIVE URN: a container that signifies the deceased individual's status as a veteran, in which the individual's cremated remains may be
placed at private expense.
b. COMMEMORATIVE PLAQUE: a commemorative plaque means a tablet that signifies the deceased individual's status as a veteran.
WHO CAN BE COMMEMORATED BY AN URN OR PLAQUE
A deceased Veteran who has been cremated with no portion of the remains interred* at any location at the time of application, and who was discharged under
conditions other than dishonorable on or after April 6, 1917, or any Servicemember of the Armed Forces of the United States who dies on active duty whose remains
have been cremated and is NOT interred at any location. 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; please submit a copy of the Reserve
Retirement Eligibility Benefits Letter with the claim. Reservists called to active duty other than training and National Guard members who are Federalized and who
serve for the period called are eligible.
* Interment means the burial or entombment of casketed or cremated remains, including the placement of cremated remains in a columbarium niche.
BENEFITS FORFEITED IF VETERAN IS COMMEMORATED BY A COMMEMORATIVE URN OR PLAQUE
Once VA issues an urn or plaque, the Veteran or Servicemember will no longer be eligible for burial in a Department of Veterans Affairs (VA) national cemetery, nor
may the VA issue a government headstone, marker, or medallion to mark the grave of, and/or memorialize the Veteran. Many Veterans and family members consider
these benefits, which will be forfeited, to be of significant monetary and symbolic value. While there is no legal prohibition against interment in a non-VA cemetery,
the family should also consider how the interment policy of these cemeteries may change if VA does not provide a government headstone, marker, or medallion at no
cost for placement in these cemeteries. For these reasons, it is critical that the family member consider the ultimate final disposition of the Veterans remains and be
certain of the decision to apply for an urn or plaque before applying.
WHO MAY APPLY FOR AN URN OR PLAQUE TO COMMEMORATE A VETERAN
The family member who holds the entirety of the cremated remains and is authorized to make decisions about the disposition of the Veteran. Family members include
the decedent's spouse or individual who was in a legal union as defined in 38 CFR 3.1702(b)(1)(ii) with the decedent; a child, parent, or sibling of the decedent,
whether biological, adopted, or step relation; and any lineal or collateral descendant of the decedent.
HOW TO SUBMIT A CLAIM
Please attach a copy of the deceased Veteran's discharge certificate (DD Form 214 or equivalent), the VA Pre-Need Eligibility Determination letter, or a copy of other official
document(s) establishing qualifying military service. If you are unable to locate copies of military records, apply anyway, as VA will attempt to obtain records necessary to make
an eligibility determination. Do not send original documents; they will not be returned.
ELECTRONICALLY submit your claim and
supporting documents by using Quick Submit
at access.va.gov. You will be instructed to
register during your first sign-on attempt.

If you prefer, you may
MAIL claims to: NCA FP Evidence Intake Center
PO Box 5237
Janesville, WI 53547

ASSISTANCE NEEDED
Should you have questions when filling out this form, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or ask.va.gov. No fee should be paid in
connection with the preparation of this claim.
TRANSPORTATION AND DELIVERY OF URN OR PLAQUE
VA will ship the commemorative urn or plaque without charge to the applicant designated in block 10a of the claim.. The applicant must provide the full delivery
address and telephone number. If you fail to include the required address and telephone number, we will not deliver the urn or plaque. Upon receipt, a signature will
be required. Unless the urn or plaque was damaged during shipping, VA will not replace the product.

VA FORM
SEP 2023

40-1330UP

Form approved, OMB No. XXXX-XXXX
Expiration Date:
Respondent Burden: 10 minutes

CLAIM FOR COMMEMORATIVE URN OR PLAQUE
FOR VETERANS CREMAINS NOT INTERRED
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 or delayed
delivery. Failure to complete each block may result in delayed processing. Blocks outlined in bold are
optional inscription items. PLEASE INCLUDE MILITARY DISCHARGE DOCUMENTS.

1. TYPE OF PRODUCT REQUESTED
PLAQUE

URN

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
2. NAME OF DECEASED VETERAN TO BE COMMEMORATED
FIRST (Or Initial)
MIDDLE (Or Initial)

LAST

SUFFIX (Sr., Jr., II, III, etc.)

4. PLACE OF BIRTH (City and State or Country)

3. VETERAN'S SOCIAL SECURITY NO. AND/OR SERVICE NO.
SSN:
AND/OR SVC. NO.:

5. RACE OR ETHNICITY (You may select more than one. Information will be used for statistical purposes only.)
ASIAN OR ASIAN AMERICAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

AMERICAN INDIAN OR ALASKA NATIVE

HISPANIC OR LATINO

NOT HISPANIC OR LATINO

WHITE

6. SEX (Information will be used for statistical purposes only.)
MALE

FEMALE

UNSPECIFIED OR ANOTHER GENDER IDENTITY

7A. DATE OF BIRTH
MONTH

DAY

7B. DATE OF DEATH
YEAR

MONTH

DAY

YEAR

PERIODS OF ACTIVE MILITARY DUTY
8A. DATE(S) ENTERED
8B. DATE(S) SEPARATED
MONTH
DAY
YEAR
MONTH
DAY
YEAR

9. BRANCH OF SERVICE (Check applicable box(es)
ARMY

NAVY

MARINE
CORPS

COAST
GUARD

AIR
FORCE

SPACE
FORCE

ARMY AIR
FORCES

MERCHANT PUBLIC HEALTH
MARINE
SERVICE

10a. NAME AND MAILING ADDRESS OF APPLICANT
(No., Street, City, State, and ZIP Code)

NATL. OCEANIC AND
ATMOSPHERIC ADMIN.

OTHER
(Specify)

10b. DAYTIME OR CELL PHONE NO. OF APPLICANT
(Include Area Code)

10c. E-MAIL ADDRESS (Optional)

11. BENEFITS FORFEITED IF FAMILY RECEIVES A COMMEMORATIVE URN OR PLAQUE FOR THE VETERAN OR SERVICEMEMBER

If VA issues an urn or plaque, the Veteran or Servicemember will no longer be eligible for burial in a Department of Veterans Affairs (VA) national
cemetery, or cemeteries operated by the Department of the Army (including Arlington National Cemetery) or Department of the Navy, nor may the
VA issue a government headstone, marker, or medallion to mark the grave of, and/or memorialize the Veteran in any cemetery. Many Veterans and
family members consider these benefits which will be forfeited to be of significant monetary and symbolic value. While there is no legal prohibition
against interment in a non-VA cemetery, the family should also consider how the interment policy of these cemeteries may change if VA does not
provide a government headstone, marker, or medallion at no cost for placement in those cemeteries. For these reasons, it is critical that the family
member consider the ultimate final disposition of the Veterans remains and be certain of the decision to apply for an urn or plaque before applying.
12. CERTIFICATION:

I certify the decedent's remains were cremated and are not interred in any location. (Interment means the burial or entombment of casketed or cremated
remains, including the placement of cremated remains in a columbarium niche.)
I certify that I (full name), _______________________________________________, understand and have considered the benefits that will be forfeited if
I apply for, and VA provides an urn or plaque (see Box 11 above);
I certify that I am the (write familial relationship)
Information Sheet and "Who May Apply");

of the Veteran or Servicemember (see

I certify that I am the family member authorized to make decisions about the disposition of the decedent's cremated remains;
I certify that I am in possession of the entirety of the cremains; and
I certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder or other offenses that could have resulted in
imprisonment for life, has never been convicted of a serious crime, and has never been convicted of a sexual offense for which the Veteran was sentenced
to a minimum of life imprisonment.
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 or for the fraudulent acceptance of any benefit to which you are not entitled.
13. SIGNATURE OF APPLICANT

VA FORM
SEP 2023

40-1330UP

14. DATE (MM/DD/YYYY)