Form VA Form 21-530A VA Form 21-530A State Application For Interment Allowance Under 38 U.S.C

OMB Control No. 2900-0565
Respondent Burden: 30 Minutes

STATE APPLICATION FOR INTERMENT ALLOWANCE UNDER 38 U.S.C. CHAPTER 23
Privacy Act Notice: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38,
Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection
of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits,
verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation
Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us the veterans’ SSN account information is
mandatory. Applicants are required to provide veterans’ SSN under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered
relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is
subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine eligibility for an interment allowance (38 U.S.C. 2303 and 2304). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at http://www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you
can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
1. NAME OF STATE

2. PLACE OF BURIAL (LOCATION OF CEMETERY)

3. RECIPIENT ORGANIZATION (Full name and address of payee)

4. CLAIM FOR MONTH ENDING

5. INTERRED VETERANS’ INFORMATION
NAME OF VETERAN
(First, middle, last)

VA FILE NO.
(C/CSS)

SOCIAL SECURITY
NUMBER

SERVICE
NUMBER

BRANCH OF
SERVICE

SERVICE DATES
TO
FROM

DATE OF
BIRTH

DATE OF
DEATH

I HEREBY CERTIFY THAT the above veterans were buried in a State-owned veterans cemetery (without charge) and are entitled to burial benefits under the provisions of Title 38, U.S.C.
6. SIGNATURE AND TITLE OF STATE OFFICIAL DELEGATED RESPONSIBILITY TO APPLY FOR FEDERAL FUNDS

TOTAL NUMBER CLAIMS APPROVED

FOR VA USE ONLY
TOTAL AMOUNT APPROVED

7. DATE SIGNED

DATE

X $300 = $
SIGNATURE OF VA APPROVING OFFICIAL

DATE
PAGE

VA FORM
AUG 2005

21-530 a

EXISTING STOCKS OF VA FORM 21-530a, AUG 2002,
WILL BE USED.

OF

BURIAL
DATE