Fillable Printable VA Form 40-10007
Fillable Printable VA Form 40-10007
VA Form 40-10007
OMB NUMBER: 2900-0784
EXPIRATION DATE: November 30, 2018
RESPONDENT BURDEN: 20 minutes
APPLICATION FOR PRE-NEED DETERMINATION OF
ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY
NOTE: Please read information on reverse before
completing this form. If additional space is required,
attach a separate sheet of paper.
Submit Application and Supporting Documentation to VA by:
Mail: to National Cemetery Scheduling Office, P.O. Box 510543, St. Louis, MO 63151; or
Fax: to the National Cemetery Scheduling Office at (855) 840-8299
IMPORTANT: Pre-Need means before death. Only complete this form if you are applying for a Pre-Need determination of eligibility for burial in a VA national
cemetery. Time of Need means time of death. DO NOT complete this form if the individual is already deceased; instead, contact a local funeral home or the National
Cemetery Scheduling Office at 1-800-535-1117 to expedite processing.
*REQUIRED ITEMS: YOU MUST COMPLETE THOSE ITEMS IDENTIFIED WITH AN ASTERISK (*)
SECTION I - VETERAN/SERVICEMEMBER
(Claims for eligibility for burial are based upon the Veterans/Servicemember's military service)
*1. VETERAN/SERVICEMEMBER NAME
(Include Suffix) (Last, First, Middle Name or Initial)
*2. NAME USED DURING MILITARY SERVICE (Include Suffix)
(If different than Item 1) (Last, First, Middle Name)
3. MAILING ADDRESS (Street, City, State,
and Zip Code, P.O. Box, Rural Route, etc.)
*4. SOCIAL SECURITY NUMBER 5. MILITARY SERVICE NUMBER (If different from SSN) 6. VA CLAIM NUMBER (If known) *7. GENDER
MALE
FEMALE
8. DATE OF BIRTH
(MM/DD/YYYY) 9. PLACE OF BIRTH (City, State or Territory)
*10. IS VETERAN/SERVICEMEMBER
DECEASED?
YES NO DON'T KNOW
11. DATE OF DEATH
(If applicable)
(MM/DD/YYYY)
*12. MARITAL STATUS
SINGLE SEPARATED MARRIED
DIVORCED WIDOWED
*13. MILITARY STATUS USED TO APPLY FOR ELIGIBILITY DETERMINATION (Check all that apply)
A. VETERAN B. RETIRED ACTIVE DUTY C. DIED ON ACTIVE DUTY
D. RETIRED RESERVE
E. RETIRED NATIONAL GUARD F. DEATH RELATED TO INACTIVE DUTY TRAINING
G. OTHER (See instructions)
MILITARY SERVICE DATA
*14. BRANCH OF SERVICE 15. DATE OF ENTRY 16. DATE OF
DISCHARGE
17. DISCHARGE - CHARACTER
OF SERVICE (See instructions)
18. HIGHEST RANK ATTAINED
(No pay grades)
19. STATE (Abbrev.)
(National Guard
Service Only)
20. IS THERE ANYONE CURRENTLY BURIED IN A VA NATIONAL CEMETERY
UNDER THIS VETERAN'S/SERVICEMEMBER'S ELIGIBILITY?
YES (Complete Item 21)
NO (Skip Item 21)
DON'T KNOW (Skip Item 21)
21. NAME OF DECEDENT(S) AND VA NATIONAL CEMETERY WHERE BURIED
22. SUPPORTING DOCUMENTS ATTACHED (See instructions for information on recommended documentation.)
YES
NO
SECTION II - CLAIMANT INFORMATION
(Information about the individual for whom determination for eligibility for burial in a VA National Cemetery is requested)
*23. CLAIMANT (See instructions) (***Each Claimant requires a separate VA Form 40-10007)
(Name) Last First Middle
WHO IS (check one):
A. THE VETERAN/SERVICEMEMBER NAMED IN ITEM 1
B. THE SPOUSE/SURVIVING SPOUSE OF THE VETERAN/SERVICEMEMBER IN ITEM 1
C. AN UNMARRIED ADULT CHILD OF THE VETERAN/SERVICEMEMBER IN ITEM 1
D. OTHER (Please specify)
*24. CLAIMANT'S MAILING ADDRESS (Street, City, State, and Zip Code,
P.O. Box, Rural Route, etc.) (If different from item 3)
25. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
*26. CLAIMANT'S SOCIAL SECURITY NUMBER (If different from item 4)
*27. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY ) (If different from item 8)
*28. CLAIMANT'S MAIDEN NAME (If applicable)
29. DESIRED VA NATIONAL CEMETERY (Optional - See instructions) 30. EMAIL ADDRESS (Optional - See instructions)
SECTION III - CERTIFICATION AND SIGNATURE
CERTIFICATION: By signing below, I certify that I am the Claimant identified in item 23, or an individual signing for the Claimant identified in Item 34. All of the
information entered on this form about the Claimant is true and correct to the best of my knowledge. A fraudulent statement that leads to burial in a national cemetery or
receiving other benefits from the VA could result in disinterment from that national cemetery and other penalties in accordance with the law. I acknowledge that otherwise
eligible individuals may be barred from burial for committing certain serious crimes, as provided under 38 U.S.C. § 2411. VA will therefore validate a previous
determination of eligibility at the time of need to check for those bars in addition to law changes or Claimant status changes that may affect eligibility of the Claimant.
*31. YOUR SIGNATURE *32. DATE *33. YOUR RELATIONSHIP TO THE CLAIMANT IN ITEM 23 (Check one; See instructions)
A. SELF (Stop here. Leave Items 34-37 blank)
B. INDIVIDUAL SIGNING FOR THE CLAIMANT who is under 18 years of age, is
mentally incompetent, or is physically unable to sign the pre-need application
(Complete items 34 through 37)
*34. NAME OF INDIVIDUAL FROM ITEM 33B COMPLETING FOR THE CLAIMANT
(Last, First, Middle Name)
*35. MAILING ADDRESS OF INDIVIDUAL COMPLETING THIS FORM FOR
THE CLAIMANT (Street, City, State, and Zip Code, P.O. Box, Rural Route, etc.)
*36. TELEPHONE NUMBER (Include Area Code) 37. EMAIL ADDRESS (Optional)
VA FORM
MAY 2017
40-10007
INSTRUCTIONS FOR COMPLETING VA FORM 40-10007 APPLICATION FOR PRE-NEED DETERMINATION OF
ELIGIBILITY FOR BURIAL IN A VA NATIONAL CEMETERY
For more complete information on eligibility requirements for burial in a VA national cemetery, visit the National Cemetery Administration
online at http://www.cem.va.gov/cem/burial_benefits/eligible.asp
or call the National Cemetery Scheduling Office at 1-800-535-1117. For
the purposes of this form, the term burial includes inurnment (above ground remains placement in a columbarium) and scattering of ashes, (if
the cemetery chosen offers those options). A Pre-Need determination of eligibility does not guarantee burial in a specific VA national
cemetery. Burial in a specific VA national cemetery will be scheduled at the Time of Need. In order to assist in completing this form,
specific instructions and explanations for certain items are given below.
SECTION I: VETERAN/SERVICEMEMBER
Eligibility for burial in a VA national cemetery is based on the qualifying service of a Veteran/Servicemember. This section of the form is
used to determine if qualifying service exists. Not all items are mandatory, however, answers to questions will aid VA in searching for
records in archives to support the claim.
Item 13 Military status used to apply for eligibility determination: For VA benefit purposes, a Veteran is a person who served in the
active military, naval, or air service, and who was discharged under conditions other than dishonorable. VA will determine on a
case-by-case basis whether certain Reserve duty qualifies. If eligibility derives from a status not listed, or if the individual is not
certain of the status, check “Other” and submit evidence of service and VA will provide appropriate assistance. Servicemembers
who die on active duty are eligible for burial. If you are arranging burial for an active duty Servicemember or his or her
dependents, you should contact a local funeral home or the National Cemetery Scheduling Office at 1-800-535-1117 to expedite
processing.
Item 17 Discharge - Character of Service: Please indicate one type of “Discharge - Character of Service”: Honorable; General; Entry
Level Separation/Uncharacterized; Other Than Honorable; Bad Conduct; or Dishonorable. If uncertain of the type of discharge or
character of service, indicate “Other” and include available supporting documents.
Item 22 Supporting military service documents: VA recommends that you attach photocopies of readily available supporting documents
so that we can make the determination quickly. Documents may include the most recent discharge document (DD Form 214)
showing the highest rank and valor awards and decorations, active duty service records other than for training purposes, or active
duty for a minimum of 24 continuous months for enlisted Servicemembers after September 7, 1980; for officers, after October 16,
1981, or the full period for which the person was called to active duty. If you are unable to locate copies of military records, apply
anyway, as VA will attempt to obtain records necessary to make a determination.
SECTION II: CLAIMANT INFORMATION
Item 23 Each Claimant requires a separate VA Form 40-10007.
23b. Spouse means a person who is or was legally married to a Veteran. Surviving Spouse mean a person who was legally married
to a Veteran at the time of the Veteran's death and includes a surviving spouse who had a subsequent remarriage. A non-Veteran
spouse of a Veteran whose marriage to the Veteran was dissolved by divorce or annulment issued by an authoritative court is not
eligible for burial in a VA national cemetery.
23c. An unmarried adult child of the Veteran is an individual who became permanently physically or mentally disabled and
incapable of self-support before reaching 21 years of age, or before reaching 23 years of age if pursuing a full-time course of
instruction at an approved educational institution. If you are making a claim for an unmarried adult child, please provide supporting
documentation such as recent medical documentation pertaining to the disability, date of onset of the disability, and the age of the
child when diagnosed with this disability. VA recommends that you provide photocopies. Note: Minor children of eligible
Veterans are eligible for burial in a VA national cemetery. The minor child of an eligible Veteran is a child who is unmarried and
who is under 21 years of age; or who is under 23 years of age and is pursuing a full-time course of instruction at an approved
educational institution.
23d. Please explain your Claimant status or relationship to the Veteran/Servicemember.
Items
29 and
30
A list of VA national cemeteries is available online at http://www.cem.va.gov/cem/cems/allnational.asp
A favorable Pre-Need
determination of eligibility does not guarantee burial in a specific national cemetery. Burial in a specific VA national
cemetery will be scheduled at the time of need. If you provide an email address, VA may use your email address to communicate
with you about your claim and burial benefits.
SECTION III: CERTIFICATION AND SIGNATURE
Items 31
and 32
The pre-need application must be signed (Item 31) and dated (Item 32) for VA to process.
Item 33 You must indicate your relationship to the claimant in Item 33.
33a. Check (A) if you are the claimant
33b. Check (B) and complete Items 34-37 if your are signing for a claimant who has not attained the age of 18 years, is mentally
incompetent, or is physically unable to sign the pre-need application. You may be a court-appointed representative, a person who is
responsible for the care of the individual (including a spouse or other relative), or an attorney in fact or agent authorized to act on
behalf of the claimant under a durable power or attorney. If the claimant is in the care of an institution, a manager or principal
officer of the institution may sign the form. Please attach supporting documents or an affidavit establishing your position relative to
the claimant.
Privacy Act Information: 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,
175VA41A, published in the Federal Register. VA considers the requested information relevant and necessary to determine maximum
benefits under the law.
Respondent Burden: Public reporting burden for this collection of information is estimated to average 20 minutes per response, including
the time to review instructions, search existing data sources, gather the necessary data, and complete and review the collection of information.
The obligation to respond is voluntary and not required to obtain or retain benefits.
REVERSE OF VA FORM 40-10007, MAY 2017
