Form 21P-530a STATE OR TRIBAL ORGANIZATION APPLICATION FOR INTERMENT A

OMB Control No. 2900-0565
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX
VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

STATE OR TRIBAL ORGANIZATION APPLICATION FOR INTERMENT ALLOWANCE
(UNDER 38 U.S.C. CHAPTER 23)
INSTRUCTIONS: Please read the Privacy Act and Respondent Burden information on Page 2 before completing this form.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly and legibly to help process the form.
1. NAME OF DECEASED VETERAN (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VETERAN'S SERVICE NUMBER (If different
from Item 2)

5. VETERAN'S DATE OF BIRTH

6. VETERAN'S PLACE OF BIRTH
(City and State)

Day

Month

Year

4. VETERAN'S FILE NUMBER

7. VETERAN'S DATE OF DEATH
Month

Day

Year

SECTION II: VETERAN'S ACTIVE DUTY SERVICE
SERVICE INFORMATION (The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE)
8B. ENTERED SERVICE

8A. BRANCH OF SERVICE

PLACE ENTERED ACTIVE SERVICE

DATE ENTERED ACTIVE SERVICE

9A. GRADE, RANK OR RATING WHEN SEPARATED
FROM SERVICE

9B. SEPARATED FROM SERVICE
PLACE LEFT ACTIVE SERVICE

DATE LEFT ACTIVE SERVICE

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

SECTION III: STATE CEMETERY OR TRIBAL ORGANIZATION INFORMATION
11. NAME OF STATE CEMETERY OR TRIBAL
ORGANIZATION CLAIMING INTERMENT ALLOWANCE

13. DATE OF BURIAL (MM/DD/YYYY)

12. PLACE OF BURIAL
A. STATE CEMETERY OR TRIBAL CEMETERY
NAME

14. RECIPIENT ORGANIZATION NAME (Full Name of Payee)

B. STATE CEMETERY OR TRIBAL CEMETERY
LOCATION

15. RECIPIENT ORGANIZATION PHONE NUMBER
(Include Area Code)

16. RECIPIENT ORGANIZATION PAYEE ADDRESS (Number and street or rural route, P.O. Box, City, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province
VA FORM
XXX XXXX

21P-530a

City
Country

ZIP Code/Postal Code
SUPERSEDES VA FORM 21P-530a, AUG 2022,
WHICH WILL NOT BE USED.

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Veteran's Social Security No.

SECTION IV: CERTIFICATION AND SIGNATURE

I HEREBY CERTIFY THAT the veteran named in Item 1 was buried in a State-owned Veterans Cemetery or Tribal Cemetery
(without charge).
17A. SIGNATURE OF STATE OR TRIBAL OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS (Sign in ink)

17B. TITLE OF STATE OR TRIBAL OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS

17C. DATE SIGNED

SECTION V: REMARKS
18. REMARKS (If any)

Mail your completed form to:
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, Wisconsin 53547-5365
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 2900-0565, and
it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 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. 2900-0565 in any correspondence. Do not send your
completed VA Form 21P-530a to this email address.

VA FORM 21P-530a, XXX XXXX

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