Fillable Printable VA Form 40-1330M
Fillable Printable VA Form 40-1330M
VA Form 40-1330M
GENERAL INFORMATION SHEET
CLAIM FOR GOVERNMENT MEDALLION FOR PLACEMENT
IN A PRIVATE CEMETERY
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 obligation to respond 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.
BENEFIT PROVIDED - MEDALLION (Only for Veterans who died on or after November 1, 1990)
Furnished 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 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 6 of the claim for further information). Eligible Veterans
may receive a Government furnished headstone or marker, or a medallion, but not both. If requesting a headstone or marker, please use the VA Form
40-1330.
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 member of the Armed Forces of the United States who dies on active duty and is buried in a private cemetery in a grave
marked with a privately purchased headstone or marker. Any deceased Veteran discharged under honorable conditions,who died on or after November 1,
1990, and is buried in a private cemetery in a grave marked with a privatelypurchased headstone or marker. A deceased Veterandischarged under
conditions other than honorable, who died on or after November 1, 1990, and isburied in a private cemetery in a grave marked with a privately purchased
headstone or marker, may also be eligible. A copy of the deceased Veteran's discharge certificate (DD Form 214 or equivalent) or a copy of other official
document(s) establishing qualifying military service must be attached. Do not send original documents; they will not be returned. Service after
September 7, 1980, 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; a copy of the Reserve Retirement Eligibility Benefits Letter must
accompany 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 - Federal regulation defines "applicant" as the decedent's Next of Kin (NOK); a person authorized in writing by the NOK; or a
personal representative authorized in writing by the decedent. Written authorization must be included with claim. A notarized statement is not required.
HOW TO SUBMIT A CLAIM
FAX 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
(disconnect the call and redial for each submission).
MAIL claims to: Memorial Programs Service (41B)
Department of Veterans Affairs
5109 Russell Road
Quantico, VA 22134-3903
A VA medallion may be furnished only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED -The applicant must sign in Block 12A. The applicant must be the Next of Kin or an authorized representative of the
decedent or the Next of Kin.
ASSISTANCE NEEDED - If assistance is needed to complete this claim, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or
via e-mail at
[email protected]. No fee should be paid in connection with the preparation of this claim. For more information regarding medallion
eligibility, affixing procedures, and sizes, visit our website atwww.cem.va.gov.
DELIVERY - The medallion is shipped without charge to the name/address designated in Block 13 of the claim. 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 are
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 cemetery.
DETACH AND RETAINTHIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
VA FORM
JAN 2015
40-1330M
ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE ON OCTOBER 1, 2014
Form approved, OMB No. 2900-0222
Expiration Date: Feb. 18, 2017
Respondent Burden: 15 minutes
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. Unless indicated otherwise all other blocks must be completed. MILITARY
DISCHARGE DOCUMENTS OR RELATED SERVICE INFORMATION ARE REQUIRED.
1. NAME OF DECEASED VETERAN
FIRST (Or Initial)MIDDLE (Or Initial)LASTSUFFIX
2. GRAVE IS:
CURRENTLY MARKED
(with privately purchased marker)
NOT MARKED
VETERAN'S SERVICE AND IDENTIFYING INFORMATION (Use numbers only, e.g., 05-15-1941)
3. VETERAN'S SOCIAL SECURITY NO. OR SERVICE NO.
SSN:SVC. NO.:
4A. DATE OF BIRTH
MONTHDAYYEAR
4B. DATE OF DEATH
MONTHDAYYEAR
PERIODS OF ACTIVE MILITARY DUTY
5A. DATE(S) ENTERED
MONTH
DAYYEAR
5B. DATE(S) SEPARATED
MONTHDAYYEAR
6. 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.
ARMYMARINE CORPSCOAST GUARDMERCHANT MARINE
NAVYAIR FORCEARMY AIR FORCES (WW II)
OTHER (USAAC,
WAAC, etc.) (Specify)
7. MEDALLION SIZE REQUESTED
(Check one) (Refer to instructions
for exact sizes)
LARGE (M5)
MEDIUM (M3)
SMALL (M1)
8. NAME AND MAILING ADDRESS OF APPLICANT
(No., Street, City, State, and ZIP Code)
9. ARE YOU:
NEXT OF KIN
(Specify Relationship)
AUTHORIZED REPRESENTATIVE ON BEHALF OF
DECEDENT (Include Written Authorization)
AUTHORIZED REPRESENTATIVE ON BEHALF OF
NEXT OF KIN (Include Written Authorization)
10. DAYTIME PHONE NO. OF APPLICANT
11. E-MAIL ADDRESS (Optional)
CERTIFICATION: By signing below I certify the medallion will be affixed to a privately purchased headstone or marker in the cemetery listed in Block
15 at no expense to the Government, and that I (or the party listed in Block 13) 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 he or she 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.
12A. SIGNATURE OF APPLICANT12B. DATE (MM/DD/YYYY)
13. NAME AND DELIVERY ADDRESS FOR MEDALLION
(No., Street, City, State, and ZIP Code); (If same as
applicant, please enter SAME)
14. DAYTIME PHONE NO.
(Include Area Code)
15. NAME AND ADDRESS OF CEMETERY WHERE PRIVATELY
PURCHASED HEADSTONE OR MARKER OF THE DECEASED VETERAN
IS LOCATED (No., Street, City, State, and ZIP Code)
VA FORM
JAN 2015
40-1330M
ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE ON OCTOBER 1, 2014
