VA40-1330M Claim for Government Medallion For Placement in a Privat

CLAIM FOR GOVERNMENT MEDALLION TO AFFIX TO A PRIVATE MARKER
GENERAL INFORMATION SHEET
RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average 15 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 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.
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 - MEDALLION (Only for eligible deceased Veterans who served in the Armed Forces on or after April 6, 1917, regardless of their date of death)
VA will furnish a medallion upon receipt of claim for affixing to an existing privately-purchased headstone or marker placed at the gravesite of an eligible deceased Veteran who is buried in a private
or local Government cemetery. The medallion is made of bronze and available in three sizes: Large, Medium, Small. Each medallion is inscribed with the word VETERAN across the top and the
Branch of Service at the bottom (see Note in Block 10 of the claim for further information).
Shown below are the three medallions with the actual dimensions (+/- 1/32") for width and height.

Large Medallion
Dimensions: 6 3/8" W, 4 3/4" H, 1/2" D

Medium Medallion
Dimensions: 3 3/4" W, 2 7/8" H, 1/4" D

Small Medallion
Dimensions: 2" W, 1 1/2" H, 1/3" D

WHO IS ELIGIBLE - Any deceased Veteran discharged under honorable conditions, who served in the Armed Forces on or after April 6, 1917, and is buried in a private cemetery in a grave marked
with a privately purchased headstone or marker. Any Servicemember of the Armed Forces of the United States who served on or after April 6, 1917, and died on active duty and is buried in a private
cemetery in a grave marked with a privately purchased headstone or marker. Service after September 7, 1980 for enlisted, and October 16, 1981 for officers, 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.
WHO CAN APPLY - An "applicant" for a Medallion may be any of the following:
(i)

A decedent's family member, which includes 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;
(ii) A personal representative, defined as a family member or other individual who has identified himself or herself as the person responsible for making decisions concerning the interment of
the remains of or memorialization of a deceased individual;
(iii) A representative of a Congressionally-chartered Veterans Service Organization;
(iv) An individual employed by the relevant state, tribal organization, or local government whose official responsibilities include serving veterans and families of veterans, such as a state or
county veterans service officer; or
(v) Any individual who is responsible, under the laws of the relevant state or locality, for the disposition of the unclaimed remains of the decedent or for other matters relating to the interment
or memorialization of the decedent.
PRESIDENTIAL MEMORIAL CERTIFICATE - A Presidential Memorial Certificate (PMC) is an engraved paper certificate, signed bearing the signature of the current president, to honor the
memory of Veterans discharged under other than dishonorable conditions. VA will provide the applicant with a PMC if the Veteran is eligible for a headstone, marker, or medallion. The applicant may
request additional PMCs by indicating how many in block 17 of this form. Applicants may use a VA Form 40-0247, Presidential Memorial Certificate Request Form to order additional PMCs to other
addresses.
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. Multiple
claims can be submitted electronically via Quick Submit.

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

FAX VA Form 40-1330M 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.

VA will furnish a medallion only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED - The claimant signs in block 18; the cemetery or other responsible official signs in block 23. If there is no official on duty at the cemetery, the signature of the person
responsible for the property listed in block 22 is required. Entries of "None," "Not Applicable," or "NA" will not be accepted.
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. If additional assistance
is needed to complete this claim, contact the nearest VA Regional Office, national cemetery, or a local veterans' organization. No fee should be paid in connection with the preparation of this claim.
DELIVERY - VA will ship the medallion without charge to the name/address designated in Block 20. The Government is not responsible for costs associated with affixing the medallion to the privately
purchased headstone or marker. Appropriate affixing adhesives, hardware and instructions will be provided with the medallion.
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. The Government is not responsible for costs associated with affixing the medallion to the privately purchased headstone or marker. Medallions furnished remain the property of the
United States Government and may not be used for any purpose other than to be affixed to the privately purchased headstone or marker of an eligible deceased Veteran buried in a private or local
Government cemetery.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
AUG 2022

40-1330M

ALL PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE

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OMB Approved No. 2900-0222
Respondent Burden: 15 minutes
Expiration Date: 09/30/2024

CLAIM FOR GOVERNMENT MEDALLION
FOR PLACEMENT IN A PRIVATE CEMETERY
IMPORTANT: Please read the General Information Sheet before completing this claim. Type or print clearly all information except for signatures. Illegible printing
could result in incorrect delivery of the medallion. Failure to complete each block may result in delayed processing. PLEASE INCLUDE COPIES OF MILITARY
DISCHARGE DOCUMENTS AND DEATH CERTIFICATE.
1. TYPE OF REQUEST

2. REASON FOR REPLACEMENT

INITIAL REQUEST (First Time)

REPLACEMENT

DAMAGE

NON-RECIEPT

INCORRECT BRANCH OF SERVICE

WRONG SIZE (Incorrect Type)
3. NAME OF DECEASED VETERAN
FIRST (Or Initial)

MIDDLE (Or Initial)

LAST

SUFFIX

4. THERE MUST BE A SET HEADSTONE, MAUSOLEUM, OR CRYPT IN PLACE TO AFFIX THE MEDALLION. IS GRAVE CURRENTLY MARKED WITH A PRIVATELY
PURCHASED PERMANENT AND DURABLE MARKER?
YES

NO

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

6. SEX AT BIRTH (Information will be used for

statistical purposes only)

NOT HISPANIC OR LATINO

AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN

MALE

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE

FEMALE

HISPANIC OR LATINO

7. SELF-IDENTIFIED GENDER IDENTITY
MAN

WOMAN

TRANSGENDER MAN

TRANSGENDER WOMAN

8. PREFERRED LANGUAGE

PREFER NOT TO ANSWER

A GENDER NOT LISTED HERE

9. PREFERRED RELIGION

VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
11. PLACE OF BIRTH (City and State or Country)

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

SVC. NO.:

PERIODS OF ACTIVE MILITARY DUTY
12A. DATE OF BIRTH

12B. DATE OF DEATH

(MM/DD/YYYY)

(MM/DD/YYYY)

13A. DATE(S) ENTERED (MM/DD/YYYY)

13B. DATE(S) SEPARATED (MM/DD/YYYY)

14. 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

SPACE FORCE

COAST GUARD

PUBLIC HEALTH SVC.

MERCHANT MARINE

NAVY

15. MEDALLION SIZE REQUESTED (Check one) (Refer to general information sheet for exact sizes)
LARGE (M5)

MEDIUM (M3)

ARMY AIR FORCES (WWII)

AIR FORCE

NATL. OCEANIC AND ATMOSPHERIC ADMIN.

SMALL (M1)

OTHER (Specify):
16. ARE REMAINS BURIED?
YES

17. APPLICANT IS:
FAMILY MEMBER (Specify Relationship):

NO

18. IF REMAINS ARE UNCLAIMED, APPLICANT IS:
FUNERAL HOME (that received remains)

VETERANS SERVICE OFFICER
PERSONAL REPRESENTATIVE (Person responsible for decisions concerning burial of decedent; include written
authorization)
OTHER (Specify):
19. NAME AND MAILING ADDRESS OF APPLICANT

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

20. DAYTIME PHONE NO.
OF APPLICANT

CEMETERY (where remains are buried)

21. E-MAIL ADDRESS (Optional)

22. PRESIDENTIAL MEMORIAL CERTIFICATE (bearing the signature of the current President) (the number you request to be mailed to you. VA will send one certificate if no

quantity is indicated and "none" is not selected)
NUMBER REQUESTED:

VA FORM
AUG 2022

40-1330M

NONE

ALL PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE

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CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in Block 22 at no expense
to the Government, and that I (or the party listed in Block 20) have agreed to accept delivery, and all information entered on this claim is true and correct to the best of my
knowledge. I also certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder or other offense 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.
24. DATE (MM/DD/YYYY)

23. SIGNATURE OF APPLICANT

25. NAME AND DELIVERY ADDRESS FOR MEDALLION

(No., Street, City, State, and ZIP Code); (If same as
applicant, please enter SAME)

26. DAYTIME PHONE NO.

(Include Area Code)

27. NAME AND ADDRESS OF CEMETERY WHERE PRIVATELY
PURCHASED HEADSTONE, MARKER, MAUSOLEUM, OR CRYPT TO
AFFIX THE MEDALLION OF THE DECEASED VETERAN IS LOCATED

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

CERTIFICATION: By signing below I certify the size medallion indicated above is permitted in the cemetery.
28. SIGNATURE OF CEMETERY OFFICIAL

VA FORM 40-1330M, AUG 2022

29. DATE (MM/DD/YYYY)

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