Form VA Form 21P-8834 VA Form 21P-8834 Application for Reimbursement of Headstone or Marker Exp

OMB Approved No. 2900-0266
Respondent Burden: 10 minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR REIMBURSEMENT OF HEADSTONE OR MARKER EXPENSE
1. NAME OF DECEASED VETERAN (First, middle, last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

5. PLACE OF BIRTH

6. DATE OF DEATH

8. DATE OF BURIAL

9. PLACE OF BURIAL OR MEMORIAL (Name and location)

3. VA FILE NUMBER

7. PLACE OF DEATH
10. WAS VETERAN BURIED OR MEMORIAL IN A
NATIONAL CEMETERY?

11. SERVICE INFORMATION
A. ENTERED SERVICE
PLACE

DATE

12. NAME OF CLAIMANT (First, middle, last)

B. SERVICE
NUMBER

C. SEPARATED FROM SERVICE
DATE

D. GRADE AND
ORGANIZATION

PLACE

E. BRANCH OF
SERVICE

13. RELATIONSHIP TO VETERAN

14. MAILING ADDRESS OF CLAIMANT

15. AMOUNT PAID
A. HEADSTONE OR MARKER

B. ENGRAVING OR EXISTING STONE
OR MARKER

$

$
16. DATE PURCHASED (Mo., day, yr.)

A. HEADSTONE OR MARKER

I CERTIFY THAT the foregoing statements made in connection with this application on account of
the named veteran are true and correct to the best of my knowledge and belief and that I have NOT
filed a separate application for a headstone.
17. SIGNATURE OF CLAIMANT

18. DATE

B. ENGRAVING

FOR VA USE ONLY
The above application has been received and is pending payment.
DATE RECEIVED

DATE FORWARD

RO NUMBER

INFORMATION AND INSTRUCTIONS FOR
COMPLETING APPLICATION FOR REIMBURSEMENT OF HEADSTONE OR MARKER EXPENSES
IN LIEU OF GOVERNMENT FURNISHED HEADSTONE OR MARKER
PRIVACY ACT INFORMATION: No reimbursement of headstone or marker may be granted unless this form is completed and returned as required by law (38 U.S.C.
Chapter 23). The responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide outside 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, Veteran
Readiness and Employment Records - VA. The requested information is considered relevant and necessary to state agencies for the purpose of determining your eligibility
to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by VA.
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 2900-0266, 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. 2900-0266 in any correspondence. Do not send your completed VA Form 21P-8834 to this email address.

HOW TO APPLY. Forward this application to the Department of Veteran Affairs Regional Office nearest you.
1. Benefits Payable. In lieu of a headstone or marker furnished at government expense, an amount not to exceed the average government cost, or the
actual cost, whichever is less, of privately procured headstones or markers (excluding base) or the additional engraving of an existing headstone or
marker already in place to include the deceased's data may be paid on a reimbursable basis when the veteran is buried or memorialized in other than a
National Cemetery. NOTE: Reimbursement applies only to headstone, marker, or engraving expenses incurred and paid subsequent to the veterans
death.
CAUTION --- This is a limited benefits and is not intended to reimburse the total cost of the selected headstone or marker.
The average government cost rate is the one in effect at the time the headstone or marker was purchased.
VA FORM
XXX XXXX

21P-8834

SUPERSEDES VA FORM 21-8834, OCT 2016,
WHICH WILL NOT BE USED.

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2. Eligibility. The deceased was:
a. Buried on or after October 18, 1978; and
b. Died on or before October 31, 1990; and
c. Was not buried or memorialized in a national cemetery, and was
d. A veteran who was discharged or released from service under conditions other than dishonorable; or
A service person who died while on active duty; or
A member of a Reserve component of the Armed Forces, Army National Guard or the Air National Guard who died while hospitalized or was
receiving treatment for a condition or disease contracted or incurred while performing reserve duties; or
A member of the Reserve Officer Training Corps whose death occurred under certain circumstances (additional information regarding this may be
obtained from your local VA regional office).
3. Who May File a Claim. Any person who paid for the veteran's or service person's headstone, marker, or additional engraving.
4. Time Limit For Filing Claim. There is no time limit for filing monetary allowance in lieu of a government furnished headstone or marker.
5. Careful Execution of Claim Necessary. Provide full information, clearly and legibly handwritten or typed. If you are unable to furnish the
information requested or if you require assistance you should contact your nearest VA Regional Office for instructions.
6. Social Security Number. Enter the deceased veteran's social security number in Item 2.
7. Veteran's Estate. If the headstone, marker, or additional engraving was paid for with funds of the veteran's estate the claim may be filed by the
executor or administrator thereof by completing the application.
8. Proof of Veteran's Death to Accompany Claim. If proof of death has previously been furnished VA, it need not be submitted with this application.
Death of veterans in Federal government institutions are automatically reported to VA and need not be proven. In all other cases the public record of
death or a copy of a coroner's report of death, or the verdict of a coroner's jury, verified by the custodial of such records must accompany this
application.
9. Receipted Bill to Accompany Claim. This claim must be accompanied by a receipted bill (preferably on the printed billhead of the monument
company) showing the name of the deceased veteran, the name of the person by whom payment was made, a description of the headstone, marker, or
additional engraving, the nature and costs of the purchase, and statement as to the amount paid by the purchaser, and all credits to the account if not paid
in full.
10. Duplication of Benefits Prohibited. This application is for use only if a headstone or marker is purchased in lieu of one furnished by VA. Claim one
benefits only. There is no entitlement to both reimbursement and a government furnished headstone or marker.
11. Service Record. If the veteran previously filed a VA claim, include the VA claim number in Item 3. If the veteran never filed a claim with VA,
submit a photocopy of his/her discharge certificate to expedite processing.
12. NOTE. The payment of any fee in the preparation of this claim is prohibited.
13. Prohibition of Discriminatory Practices. Reimbursement of headstone, marker, or additional engraving expenses prohibited if the retailer is found to
discriminate based on race, color, or national origin (42 U.S.C. 2000(d)). Any person(s) who purchases a headstone, marker, or additional engraving has
the right to file a complaint with the nearest VA Regional Office if discrimination is encountered.

VA FORM 21P-8834, XXX XXXX

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