Form VA40-1330UP Claim for Commemorative Urn or Plaque For Veterans Crema

CLAIM FOR COMMEMORATIVE URN OR PLAQUE FOR VETERANS' CREMAINS NOT INTERRED
GENERAL INFORMATION SHEET
RESPONDENT BURDEN - An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 2900-0937, and it expires XX/XX/20XX. Public reporting burden for this collection of information is
estimated to average 10 minutes per respondent, per year, 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 and any other aspect of this collection of information,
including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0937 in any
correspondence. Do not send your completed VA Form 40-1330UP to this email 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 for enlisted personnel, and October
16, 1981 for officer personnel, 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 IN-LIEU OF A COMMEMORATIVE URN OR PLAQUE - A commemorative urn or plaque may only be provided in-lieu of other benefits
that will be forfeited. If VA provides an urn or plaque for a Veteran or Servicemember, VA is prohibited from interring the Veteran or Servicemember in a VA national
cemetery or providing a headstone or marker or medallion that would mark the Veterans grave. If VA provides an applicant a commemorative urn or plaque to commemorate a
Veteran it may also negatively impact interment in other cemeteries including, but not limited to, cemeteries operated by the Department of Defense, including Arlington
National Cemetery. VA encourages potential applicants for a commemorative urn or plaque who might seek interment in the future to check directly with other cemeteries
regarding its effect on potential interment at those cemeteries. VA encourages careful consideration of the consequences before applying to VA for a commemorative urn or
plaque. Many Veterans and family members consider the benefits which will be forfeited to be of greater monetary and symbolic value than an urn or plaque. Consideration
should also be given to the future disposition of the remains of a Veteran or Servicemember for whom an urn or plaque has been provided. Because options for future interment
are more limited, there is greater risk for remains to become lost or unclaimed throughout time. For these reasons, it is critical that the family member consider the final
disposition of the Veteran's remains and be certain of their decision before completing this application for an urn or plaque.
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 at:
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
APR 2024

40-1330UP

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OMB Approved No. 2900-0937
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX

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 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)

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

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

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

LAST

SVC. NO.:

5. VETERAN'S RACE AND/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

PERIODS OF ACTIVE MILITARY DUTY
7A. DATE OF BIRTH

7B. DATE OF DEATH

(MM/DD/YYYY)

(MM/DD/YYYY)

8A. DATE(S) ENTERED (MM/DD/YYYY)

8B. DATE(S) SEPARATED (MM/DD/YYYY)

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

MARINE CORPS

SPACE FORCE

COAST GUARD

PUBLIC HEALTH SVC.

MERCHANT MARINE

NAVY

NATL. OCEANIC AND ATMOSPHERIC ADMIN.

AIR FORCE

ARMY AIR FORCES (WWII)

OTHER (Specify):

APPLICANT INFORMATION AND CERTIFICATION
10A. NAME AND MAILING ADDRESS OF APPLICANT

(No., Street, City, State, and ZIP Code)

10B. DAYTIME PHONE NO.
OF APPLICANT

10C. E-MAIL ADDRESS (Optional)

11. BENEFITS FORFEITED IN-LIEU OF A COMMEMORATIVE URN OR PLAQUE
A commemorative urn or plaque may only be provided in-lieu of other benefits that will be forfeited. If VA provides an urn or plaque for a Veteran or Servicemember, VA
is prohibited from interring the Veteran or Servicemember in a VA national cemetery or providing a headstone or marker or medallion that would mark the Veterans grave.
If VA provides an applicant a commemorative urn or plaque to commemorate a Veteran it may also negatively impact interment in other cemeteries including, but not
limited to, cemeteries operated by the Department of Defense, including Arlington National Cemetery. VA encourages potential applicants for a commemorative urn or
plaque who might seek interment in the future to check directly with other cemeteries regarding its effect on potential interment at those cemeteries. VA encourages careful
consideration of the consequences before applying to VA for a commemorative urn or plaque. Many Veterans and family members consider the benefits which will be
forfeited to be of greater monetary and symbolic value than an urn or plaque. Consideration should also be given to the future disposition of the remains of a Veteran or
Servicemember for whom an urn or plaque has been provided. Because options for future interment are more limited, there is greater risk for remains to become lost or
unclaimed throughout time. For these reasons, it is critical that the family member consider the final disposition of the Veteran's remains and be certain of their decision
before completing this application for an urn or plaque.
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 VA benefits that will be forfeited if I apply for, and VA
provides, an urn or plaque (see Box 11 above); and I understand that interment in other cemeteries may be affected by the provision of a VA commemorative urn or plaque.
I certify that I am the

(familial relationship) of the Veteran or Servicemember (see Information Sheet and "Who May Apply");

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 remains; 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
or a period of 99 years or more.
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
APR 2024

40-1330UP

14. DATE (MM/DD/YYYY)

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