Form VA Form 21P-530EZ VA Form 21P-530EZ Application for Burial Benefits

NOTICE OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM
FOR BURIAL BENEFITS (UNDER 38 U.S.C., CHAPTER 23)
This notice provides information regarding the evidence necessary to substantiate a claim for:
• Non-service-connected Burial Allowance
• Service-connected Burial Allowance
• Plot or Interment Allowance
• Transportation Reimbursement
• Unclaimed Remains of Veteran

When to Use this Form
Use this notice and the attached application to submit a claim for any of the above named burial allowances and related burial benefits. This notice informs
you of the evidence necessary to decide your claim. After you submit your claim on the attached application, you will not receive an initial letter regarding
your claim. You do not need to submit another application.
If you are filing a claim for new burial benefits or disagree with
an evaluation decided more than one year ago...
If you disagree with a burial decided within the past year and
have new and relevant evidence OR
If you are filing a supplemental claim (a claim after an initial
claim for the same burial benefit(s) previously decided)...

Please complete and submit VA Form 21P-530EZ, Application for
Burial Benefits
Please complete and submit VA Form 20-0995, Decision Review
Request: Supplement Claim**

**You may also file a request for a higher-level review or an appeal to the Board of Veterans' Appeals. For additional information on all these different
options, please visit https://benefits.va.gov/benefits/appeals.asp.

Want to apply electronically?

You can apply for VA burial benefits online at https://www.va.gov/. You can also upload all supporting evidence you may have and make your claim a
Fully Developed Claim (FDC).
NOTE: You may wish to contact an accredited Veterans Service Officer (VSO) to assist you with your application. For a list of accredited Veterans
Service Organizations go to https://www.va.gov/vso/. You may also contact your state office of Veterans Affairs at https://www.va.gov/statedva.htm
should you need further assistance with the application process.

Want your claim processed faster?
The FDC Program is the fastest way to get your claim processed without any risk to participate! To participate, submit your claim in accordance with the
"FDC Criteria" shown below. If you are making a claim for survivor benefits, use VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or
Accrued Benefits. VA forms are available at www.va.gov/vaforms.
NOTE: Participation in the FDC program is optional and will not affect the benefits to which you are entitled. If you file a claim in the FDC Program and
it is determined that other records exist and VA needs the records to decide your claim, then VA will simply remove the claim from the FDC Program and
process it in the Standard Claim Process. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited Process) on page 3. If
you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process on page 3.
FEES for claims: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding
fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the
Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or
agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and
the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.

VA FORM
XXX XXXX

21P-530EZ

SUPERSEDES VA FORM 21P-530, AUG 2022

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GENERAL INFORMATION
ELIGIBLE CLAIMANTS (Who Should File A Claim):
Check the appropriate box on the form (Item 13) regarding your relationship to the veteran to certify your correct claimant eligibility.
VA may grant a claim that any eligible person files. Upon death of the veteran, VA will pay the first living person to file a claim of those listed below:
• The veteran's surviving spouse; OR
• The survivor of a legal union between the deceased veteran and the survivor; OR
• The veteran's children, regardless of age (biological, step and adopted); OR
• The veteran's parents or the surviving parent; OR
• The executor or administrator of the deceased veteran's estate, or person acting for the deceased veteran's estate (a person is considered acting for the
estate when no executor or administrator has been appointed).
• For purposes of this application, legal union means a formal relationship between the veteran and the survivor that existed on the date of the veteran's
death, was recognized under the law of the State in which the couple formalized to relationship and was evidenced by the State's issuance of
documentation memorializing the relationship.
If the veteran's remains are unclaimed, VA will pay the person or entity that provided burial services for the remains of an unclaimed veteran.
NOTE: Claimant Social Security Number and date of birth are not required when claiming unclaimed remains, or if the claimant is a firm, corporation, or
state agency.
TIME LIMIT FOR FILING A CLAIM: Claim for non-service-connected burial allowance must be filed with VA within 2 years after the date of the
veteran's permanent burial or cremation. If a veteran's discharge was corrected after death to "Under Conditions Other Than Dishonorable," the claim must
be filed within 2 years after the date of correction. There is no time limit for the service-connected burial allowance, plot or interment allowance, nonservice-connected burial allowance based upon VA hospitalization death, or reimbursement of transportation expenses.
BURIAL ALLOWANCE: A one-time benefit payment payable toward the expenses of the funeral and burial of the veteran's remains. Burial includes all
legal methods of disposing of the veteran's remains including, but not limited to, cremation, burial at sea and medical school donation. (See evidence table
for more information.)
PLOT OR INTERMENT ALLOWANCE: A one-time benefit payment payable toward:
(1) Expenses incurred for the plot or interment of a Veteran who was eligible for burial in a national cemetery if the actual burial was not in a national
cemetery under the jurisdiction of the United States and non-service-connected burial allowance is granted; OR
(2) Expenses are payable if non-service-connected burial allowance is granted and veteran was buried in a State-owned cemetery or sub-section used
solely for the remains of such persons or other individuals as authorized within 38 U.S.C. 2303(b)(1) and meets eligibility for burial in a national
cemetery.
"Plot" means the final disposition site of the remains, whether it is a grave, mausoleum vault, columbarium niche, or similar place.
"Interment" means the burial of casketed remains in the ground or the placement of cremated remains into a columbarium niche.
TRANSPORTATION REIMBURSEMENT: When transportation reimbursement is allowable, VA may pay for expenses relating to the transportation of
the veteran's remains. This includes the pickup and the transportation of the veteran's remains to their final resting place. Claims for transportation
reimbursement benefits must include a statement of account showing itemized transportation charges.
VA may pay transportation reimbursement only when one of the following eligibility requirements are met:
• VA hospitalization death; OR
• the veteran was in receipt of disability compensation at the time of death; OR
• the veteran was in receipt of military retirement in lieu of disability compensation at the time of death; OR
• the veteran was in receipt of pension at the time of death; OR
• the veteran's remains are unclaimed; OR
• Service-connected burial allowance granted and burial was in a national or covered Veteran's cemetery.
NOTE: a covered Veterans' cemetery is defined as a Veterans' cemetery in which a deceased veteran is eligible to be buried that is owned by a State or is
on trust land owned by, or held in trust for, a tribal organization, and for which the Secretary has made a grant under 38 U.S.C. 2408.
PROOF OF DEATH TO ACCOMPANY CLAIM: Death in a government institution does not need to be proven. In other cases, the claimant must
forward a copy of the public record of death. If the proof of death has previously been furnished to VA, it does not need to be submitted again.
Claims for service-connected burial allowance must include the veteran's cause of death.
RESPONSIBLE FOR (LEGALLY INCURRED) EXPENSES: The claimant (you) have already paid or owe the burial expenses for the benefit being
claimed and is legally the responsible party for the debt. By checking "Yes" in Item 22A on the form, you are certifying that this statement is true. If filing
as an executor of the veteran's estate, by checking "Yes" in Item 22A, you certify that the veteran paid the burial prior to his or her death or funds from the
estate were used as payment.
SERVICE RECORD: A photocopy of the veteran's DD Form 214, Report of Separation (or equivalent) for all periods of military service will permit
prompt processing. You may request a copy of the DD Form 214 through the National Archives' National Personnel Records Center (NPRC) using SF 180
(09/2021 version), Request Pertaining to Military Records, (available at https://www.archives.gov/) or through your local public custodian of records.
Service documents will not be returned. If the veteran was receiving VA benefits, this is not required with your application.

VA FORM 21P-530EZ, XXX XXXX

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SUBMITTING A CLAIM
When submitting a claim(s) for Burial Benefits the following information tells you what you need to do and what VA will do during the FDC Program
(Optional Expedited Process) or the Standard Claim Process:
HOW TO SUBMIT A CLAIM: Submit your claim on a VA Form 21P-530EZ, Application for Burial Benefits (attached). Make sure you complete and
sign your application.
WHAT YOU NEED TO DO: The tables beginning on page 3 describes the information and evidence you need to submit based on if you wish to have
your claim considered in the FDC Program (Optional Expedited Process) or in the Standard Claim Process. You will need to indicate how you want your
claim to be processed by checking the appropriate box in Section VII on page 7 of this form.

FDC Program (Optional Expedited Process)
You must submit:
• A signed and FULLY COMPLETE VA Form 21P-530EZ,
Application for Burial Benefits
• Required evidence for each burial benefit claimed (see tables below)
• Complete veteran and claimant information
• Proof of veteran's death, including the cause of death, if claiming
service-connected burial allowance. If the veteran was seen outside of
the VA, you must include copies of any medical records from a
private medical provider or provide a completed VA Form 21-4142,
Authorization to Disclose Information to the Department of Veterans
Affairs (VA) and VA Form 21-4142a, General Release for Medical
Provider Information to the Department of Veterans Affairs (VA),
with your application for VA to request the records on your behalf
• An itemized statement of account, if claiming transportation
reimbursement
NOTE: If you decide to submit your claim through the FDC Program,
please indicate FDC in Section VII of the application on page 7.
You must:
• Send the above information and any specific evidence listed below
for the burial benefit(s) claimed along with your claim form
If you submit additional information or evidence after you submit your
"fully developed" claim, then VA will remove the claim from the FDC
Program (Optional Expedited Process) and process it in the Standard Claim
Process. If we decide your claim before one year from the date we receive
the claim, you will still have the remainder of the one-year period to submit
additional information or evidence necessary to support the claim.

Standard Claim Process
Please submit a complete signed VA Form 21P-530EZ, Application for
Burial Benefits, that includes any required evidence listed in the tables
below.
If you know of any evidence not in your possession and want VA to try to
get it for you;
You must:
• Complete and sign VA Form 21-4142 and VA Form 21-4142a,
identifying any private medical records you wish VA to request for
you
• Give VA enough information about other relevant evidence so that
we can request it from the person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a fee to
provide it, or otherwise cannot get the evidence, VA will notify you and
provide you with an opportunity to submit the information or evidence. It
is your responsibility to make sure we receive all requested records that
are not in the possession of a Federal department or agency.
You are strongly encouraged to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to submit the
information and evidence necessary to support your claim. If within 30
days, you do not provide any evidence or do not provide us with the
information requested to assist you with obtaining evidence, we may
decide your claim prior to the expiration of the one year period. If we
decide the claim before one year from the date we receive the claim, you
will still have the remainder of the one year period to submit additional
information or evidence necessary to support the claim.

HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM: The table below describes the information and evidence VA will assist you in
obtaining based on whether you wish to have your claim considered in the FDC Program (Optional Expedited Process) or in the Standard Claim Process.

FDC Program (Optional Expedited Process)
VA will:
• Retrieve relevant records from a Federal facility, such as a VA
Medical Center, that you adequately identify and authorized VA to
obtain.
• Provide a medical examination for you, or get a medical opinion, if
we determine it is necessary to decide your claim.

Standard Claim Process
VA will:
• Retrieve relevant records from a Federal facility, such as a VA
Medical Center, that you adequately identify and authorized VA to
obtain.
• Provide a medical examination for you, or get a medical opinion, if
we determine it is necessary to decide your claim.
• Make every reasonable effort to obtain relevant records not held by a
Federal facility that you adequately identify and authorize VA to
obtain. These may include records from State or local governments
and privately held evidence and information you tell us about, such as
a private doctor or hospital records from current or former employers.

WHERE TO SEND INFORMATION AND EVIDENCE: You may send your application and any evidence in support of your claim by using any of the
following methods shown in the table below.

VA FORM 21P-530EZ, XXX XXXX

MAIL TO

ONLINE

Department of Veterans Affairs
Pension Claims Intake Center
P.O. Box 5365
Janesville, WI 53547-5365

https://www.va.gov/

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WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM: The tables below show what evidence you must provide and eligibility
information to support your claim for burial benefits.
EVIDENCE TABLES
Non-Service-Connected Burial Allowance
To support a claim for non-service-connected burial allowance, the evidence mush show:
• VA received a burial claim for non-service-connected burial allowance no later than two years after the burial or cremation of the veteran; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the estate and is applying
on behalf of the veteran who incurred the expenses; AND
• Verification of veteran's military service (only if veteran was not in receipt of VA benefits at time of death; AND
• At the time of death, the veteran:
• Was in receipt of VA disability compensation or VA pension; OR
• Had a claim pending which would have resulted in entitlement to VA disability compensation or VA pension; OR
• Was entitled to receive VA disability compensation or VA pension but decided to receive military retirement or disability pay in place of VA
disability compensation check.
• Was hospitalized by VA. For VA hospitalization, for the purpose of this burial benefit, VA hospitalization is met, if at the time of death, the
veteran:
• Was properly admitted to a VA facility; OR
• Was transferred or admitted to a non-VA facility for hospital care under VA contract; OR
• Was transferred or admitted to a nursing home for nursing home care at the expense of the VA contract; OR
• Was traveling under proper prior authorization to or from a specified place for purpose of examination treatment or care, at VA expense; OR
• Was transferred or admitted to a State nursing home at the expense of the VA, under VA contract; OR
• Was a patient in a State Veteran's home.
Service-Connected Burial Allowance
To support a claim for service-connected burial allowance, the evidence must show:
• VA received a burial claim for service-connected burial allowance; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death including the cause of death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the estate and is applying
on behalf of the veteran who incurred the expenses; AND
• Verification of the veteran's military service (only if the veteran was not in receipt of VA benefits at the time of death; AND
• If your claim is based on a service-connected disability established during the veteran's lifetime, the evidence must show:
• The veteran had a service-connected disability(ies) that was/were either the principal or contributory cause of the veteran's death; OR
• If your claim is based on a disability that was not established as service-connected during the veteran's lifetime or for which the veteran did not
file a claim during his or her lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active military service, or an event in service that caused an injury or disease;
AND
• A physical or mental disability that was either the principle and contributory cause of death. This may be shown by medical evidence or by
lay evidence of persistent and recurrent symptoms of a disability that were visible or observable; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in military service. Medical records
or medical opinions are generally required to establish this relationship.
Unclaimed Remains
In order to support a claim for unclaimed remains, the evidence must show:
• VA received a burial claim for veteran's unclaimed remains no later than two years after the burial or cremation of the veteran; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred burial expenses of the deceased veteran; AND
• The remains of the deceased veteran have not been claimed by relatives or friends; AND
• There are not sufficient resources available in the veteran's estate to cover the burial and funeral expenses.
NOTE: Funeral homes and/or entities in care and custody of remains who incurred costs for burial of unclaimed veteran remains may file a claim for
burial benefits as the claimant responsible for the expense. When filing a claim, check "Yes" in Item 22A as the responsible party for the burial expense
if you incurred costs due to the service you provided in burial or cremation of the remains. By checking "Yes", you are certifying that you incurred the
costs and no one other than you is responsible for the expense.
VA FORM 21P-530EZ, XXX XXXX

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EVIDENCE TABLES (Continued)
Plot or Interment Allowances
In order to support a claim for plot or interment allowance, the evidence must show:
• VA received a burial claim for plot or interment allowance; AND
• You are an eligible claimant authorized burial benefits; AND
• Veterans burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred plot or interment expenses, or claimant is the executor of the estate and is applying on behalf of the
veteran who incurred the expenses; AND
• Veterans burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery.
Transportation Reimbursement
To support your claim for transportation reimbursement, the evidence mush show:
• VA received a burial claim for transportation reimbursement; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred transportation expenses of the deceased veteran, or claimant is the executor of the estate and is
applying on behalf of the veteran who incurred the expenses; AND
• An itemized receipt or statement, preferably on letterhead that includes the:
• Name of the deceased veteran; AND
• Specific transportation costs incurred; AND
• Date of the services rendered; AND
• Name of the individual who paid the costs.

HOW VA DETERMINES THE EFFECTIVE DATE

Burial benefits are based on the date of the veteran's death and the death date we receive your claim. The veteran's death certificate is relevant evidence used
in determining the effective date of any benefits we award.

VA FORM 21P-530EZ, XXX XXXX

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OMB Approved No. 2900-0003
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR BURIAL BENEFITS
(Under 38 U.S.C. Chapter 23)

VA DATE STAMP

IMPORTANT: Please read the Privacy Act and Respondent Burden on page 8 before completing the form.
SELECT THE TYPE OF CLAIM PROGRAM/PROCESS IN SECTION VII, PAGE 7 ON THE FORM (Check the
appropriate box) (See instructions on page 3)

(DO NOT WRITE IN THIS SPACE)

NOTE: You can either complete the form online or by hand. If you complete the form online, you may submit it at
VA.gov to expedite processing. If you complete the form by hand, please print the information requested in ink,
neatly, and legibly to help process the form.

SECTION I - PERSONAL IDENTIFICATION OF VETERAN
1. NAME OF THE DECEASED VETERAN (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S DATE OF DEATH (MM/DD/YYYY)

6. VETERAN'S DATE OF BURIAL (MM/DD/YYYY)

SECTION II - CLAIMANT'S INFORMATION
7. CLAIMANT'S NAME (First, Middle Initial, Last)

8. CLAIMANT'S SOCIAL SECURITY NUMBER (See instructions for exceptions)

9. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY) (See instructions for exceptions)

10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

11. TELEPHONE NUMBER (Include Area Code)

12. E-MAIL ADDRESS

13. RELATIONSHIP OF CLAIMANT TO DECEASED VETERAN (Check one)
SPOUSE OR SURVIVOR OF LEGAL UNION

EXECUTOR/ADMINISTRATOR OF ESTATE OR PERSON ACTING FOR THE ESTATE

CHILD

FUNERAL HOME OR OTHER THIRD PARTY

PARENT

OTHER RELATIVE OR FRIEND OF THE DECEASED (Non-Executor)

SECTION III - VETERAN'S SERVICE INFORMATION
The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE
14A. ENTERED SERVICE
DATE

(MM/DD/YYYY)

PLACE

14B. SERVICE
NUMBER

14C. SEPARATED FROM SERVICE
DATE

(MM/DD/YYYY)

PLACE

14D. GRADE, RANK OR RATING,
ORGANIZATION AND BRANCH OF SERVICE

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

VA FORM
XXX XXXX

21P-530EZ

SUPERSEDES VA FORM 21P-530, AUG 2022.

Page 6

VETERAN'S SSN (Pre-populated from Page 6)

SECTION IV - INFORMATION REGARDING FINAL RESTING PLACE
16. PLACE OF BURIAL PLOT, INTERMENT SITE, OR FINAL RESTING PLACE OF DECEASED VETERAN'S REMAINS
CEMETERY/GRAVEYARD

PRIVATE RESIDENCE

MAUSOLEUM/VAULT/TOMB/CRYPT

OTHER (Specify):

17. WAS THE VETERAN BURIED IN A NATIONAL CEMETERY, OR ONE
OWNED BY THE FEDERAL GOVERNMENT?
YES

18. WAS THE VETERAN BURIED IN A CEMETERY OWNED BY THE STATE OR TRIBAL
TRUST LAND?

NO

YES, State Cemetery

(If "YES," provide name of cemetery below):

YES, Tribal Trust

NO

(If "YES," provide name and zip code of cemetery or Tribal Trust Land below):
NAME:

19A. DID A FEDERAL/STATE GOVERNMENT OR THE VETERAN'S
EMPLOYER CONTRIBUTE TO THE BURIAL?
YES

NO

ZIP CODE:

19B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION
$

(If "YES," complete Item 19B)

.00

SECTION V - CLAIM FOR BURIAL ALLOWANCE
20A. SELECT TYPE OF BURIAL ALLOWANCE YOU ARE CLAIMING

20B. WHERE DID THE VETERAN'S DEATH OCCUR? (Check one)

(May apply for more than one)

NURSING HOME/FACILITY (NOT PAID BY VA) OR VETERANS RESIDENCE

NON-SERVICE-CONNECTED BURIAL ALLOWANCE

NURSING HOME/FACILITY (PAID BY VA)*

SERVICE-CONNECTED BURIAL ALLOWANCE

VA MEDICAL CENTER*

UNCLAIMED REMAINS OF THE VETERAN

STATE VETERANS FACILITY*

(If claimed, you must answer question 20B)

OTHER (Specify place of death)*:

*Please provide veteran's specific place of death including the name and location of the
nursing home, VA Medical Center or State veteran facility.

21. IF YOU ARE THE DECEASED VETERAN'S SPOUSE, DID YOU PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
22A. ARE YOU RESPONSIBLE FOR THE VETERAN'S BURIAL EXPENSES?

YES

YES

NO

NO

22B. DO YOU CERTIFY THE REMAINS OF THE DECEASED VETERAN HAVE NOT BEEN CLAIMED BY RELATIVES OR FRIENDS AND THERE ARE NOT SUFFICIENT
RESOURCES AVAILABLE IN THE VETERAN'S ESTATE TO COVER THE BURIAL AND FUNERAL EXPENSES? (Required only if claiming unclaimed remains of veteran)
YES

NO

SECTION VI - CLAIM FOR PLOT AND/OR TRANSPORTATION ALLOWANCE
23. ARE YOU RESPONSIBLE FOR THE VETERAN'S PLOT OR INTERMENT EXPENSES?

YES

NO

24. ARE YOU RESPONSIBLE FOR THE VETERAN'S TRANSPORTATION EXPENSES FROM THE PLACE OF DEATH TO THE FINAL RESTING PLACE? (You must include

an itemized receipt)
YES

NO

SECTION VII - CLAIM CERTIFICATION AND SIGNATURES (MUST COMPLETE)
CLAIMANT CERTIFICATION AND SIGNATURE
I WANT my claim processed under the FDC program. I CERTIFY and authorize the release of information. I CERTIFY that the statements in this document are true
and complete to the best of my knowledge. I AUTHORIZE any person or entity, including but not limited to any organization, service provider, employer, or
government agency, to give the Department of Veterans Affairs any information about me and the veteran, and I WAIVE any privilege which makes the information
confidential. I CERTIFY I have received the notice attached to this application titled, Application for Burial Benefits, and, I CERTIFY I have enclosed all the
information or evidence that will support my claim, to include an identification of relevant records available at a Federal facility such as a VA medical center; or, I have
no additional information or evidence to give VA to support my claim.
I do not want my claim processed under the FDC program. I am indicating I want my claim processed under the standard claim process because I plan to submit
further evidence in support of my claim.
25A. SIGNATURE OF CLAIMANT (REQUIRED) (Sign in ink) (If signed using an "X",

25B. PRINTED NAME OF CLAIMANT

26A. FULL PRINTED NAME AND ADDRESS OF PERSON, FIRM, CORPORATION,
OR STATE AGENCY SIGNING AS CLAIMANT (If different from Item 7)

26B. OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM,
CORPORATION OR STATE AGENCY

complete Items 27A through 28B) (If signing for a firm, corporation, or State
agency, complete Items 26A and 26B)

VA FORM 21P-530EZ, XXX XXXX

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VETERAN'S SSN (Pre-populated from Page 6)

SECTION VIII - WITNESSES TO SIGNATURE
NOTE: If the claimant signed above using an "X", a signature must be witnessed by two persons to whom the person making the statement and the signatures
and addresses of such witnesses must be shown below.
27A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in

27B. PRINTED NAME AND ADDRESS OF WITNESS

28A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in

28B. PRINTED NAME AND ADDRESS OF WITNESS

Item 25A used an "X")

Item 25A used an "X")

SECTION IX - ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (REQUIRED ONLY IF ITEM 25A IS BLANK)
I CERTIFY THAT by signing on behalf of the claimant, I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I UNDERSTAND that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also
understand that VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of
the claimant if necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number
(TIN); a certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/
time stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and
your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the
care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
29A. ALTERNATE SIGNER SIGNATURE (REQUIRED only if Item 25A is blank) (Physical Signature)

29B. DATE SIGNED (MM/DD/YYYY)

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: 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 2900-0003, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 30 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. 2900-0003 in any correspondence. Do not send your completed VA Form 21P-530EZ to this email address.

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.
DEPARTMENT OF VETERANS AFFAIRS HEADSTONES AND MARKERS
The Department of Veterans Affairs will furnish, upon request, a Government headstone or marker at the expense of the United States for the unmarked
graves of certain individuals eligible for burial in a national cemetery, but not buried there. These individuals may include any veterans with an other
than dishonorable discharge who dies after service or any servicemember who dies on active duty. Certain other individuals may also be eligible for the
headstone or marker. Headstones or Markers for all individuals in a national or post cemetery are furnished automatically without a request from the
family. For additional information on burial benefits go to the web site, www.cem.va.gov/bbene_burial.asp. To obtain VA Form 40-1330, Application
for Standard Government Headstone or Marker, go to www.va.gov/vaforms or contact your local VA regional office. The address of that office can be
found at www.va.gov/directory.

VA FORM 21P-530EZ, XXX XXXX

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