Form 40-10232 Request for Payment of Monetary Allowance for Outer Buri

Form Approved, OMB No. 2900-0941
Respondent Burden: 15 minutes
Expiration Date:

REQUEST FOR PAYMENT OF MONETARY ALLOWANCE FOR OUTER BURIAL RECEPTACLES
(For burials in a cemetery that is the subject of a grant to a State or Tribal Organization
under 38 U.S.C. 2408, in accordance with 38 CFR §38.629(d) and (e))
PRIVACY ACT INFORMATION: 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 as identified in the VA system of records, 13VA047, Individuals Submitting InvoicesVouchers for Payment and Accounting Transactional Data-VA, as published in the Federal Register on August 31, 2023 (88 FR 60269). The requested information
is considered relevant and necessary to process payment of the monetary allowance as authorized by 38 U.S.C. 2306(e).
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 2900-0941, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 15 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. 2900-0941 in any correspondence. Do not send your completed VA Form 40-10232 to this email address.
INSTRUCTIONS: Statutory authority for payment of monetary allowance for outer burial receptacles is 38 U.S.C. 2306(e). Type or print clearly all information
required.
Part A: Individuals should use Part A of this form to request payment of the monetary allowance for a privately purchased outer burial receptacle for burials on or
after January 5, 2023 in a cemetery that is the subject of a grant to a State or Tribal Organization under 38 U.S.C. 2408. Applicants must also provide evidence of
payment, such as a paid invoice or purchase receipt. Applications and proof of purchase for this part should be submitted to the National Cemetery Administration,
Finance Service via fax 1-314-416-6340 or via mail to National Cemetery Administration, Attention: VCGP OBR Allowance, P.O. Box 141, Triangle, VA 22172,
or via email to VANCAOBRALLOWANCE@va.gov.
Part B: State Agencies and Tribal Organizations should use Part B of this form to request quarterly payment of the monetary allowance for outer burial receptacles
placed at the time of interment on or after January 5, 2023 in a cemetery that is the subject of a grant to a State or Tribal Organization under 38 U.S.C. 2408.
Applications for this part should be submitted to: the National Cemetery Administration, Office of the VCGP via email to vcgp@va.gov.
Part B applicants must also have a Vendor ID on file with the VA Finance Service Center (FCS). Applicants who do not have a Vendor ID may request one through
the Customer Engagement Portal (va.gov), using a digital version of the VA Form 10091 (VA-FSC Vendor File Request Form). Please note that vendors must first
register with https://www.id.me/, a simple and secure identity verification system, to use the portal.

PART A - Allowance for Privately Purchased Outer Burial Receptacles (IAW 38 C.F.R. § 38.629(d)(2))
1. APPLICANT NAME

2. ADDRESS

3. PHONE ((999) 999-9999)

4. EMAIL ADDRESS

5. NAME OF DECEASED

6. DATE OF INTERMENT (MM/DD/YYYY)

7. NAME OF CEMETERY WHERE INTERRED

8. STATION ID

9. BURIAL SITE ID

CERTIFICATION

By signing below I certify that I paid for the outer burial receptacle used for the burial identified above and am attaching proof of purchase to this
application.
10. SIGNATURE OF APPLICANT (Sign in ink)

11. DATE (MM/DD/YYYY)

By signing below I certify a privately purchased outer burial receptacle was used for the interment identified above.
12. SIGNATURE OF CEMETERY OFFICIAL (Sign in ink)

13. DATE (MM/DD/YYYY)

14. TYPE OR PRINTED NAME OF CEMETERY OFFICIAL

15. TITLE

16. PHONE ((999) 999-9999)

17. EMAIL

VA FORM
SEP 2024

40-10232

Page 1

PART B - Monetary Allowance for Outer Burial Receptacles Placed at Time of Interment
(IAW 38 C.F.R. § 38.629(e))
1. STATE AGENCY OR TRIBAL ORGANIZATION

2. FEDERAL ACQUISITION ID

3. VENDOR ID

4. PERIOD OF REQUEST
YEAR

QUARTER

JAN - MAR

APR - JUN

JUL - SEP

OCT - DEC

For each cemetery below, attach a list showing the gravesite location identifier and date of interment for each outer burial receptacle used at time
of interment for the period indicated above. Also, for each cemetery below, provide a gravesite layout map where gravesite locations can be
identified using the gravesite location identifier.
5a. CEMETERY NAME

b. STATION ID

c. QUANTITY
USED

d. OBR ALLOWANCE
AMOUNT

e. AMOUNT CLAIMED

TOTAL

By signing below, I certify the following:
1. This request for payment includes only casketed interments where an outer burial receptacle was placed at the time of interment.
2. Outer burial receptacles used were paid for by the State or Tribal Organization requesting payment.
3. No fees for such outer burial receptacle were charged to the decedent's family or other responsible party.
6. SIGNATURE OF AUTHORIZED STATE OR TRIBAL OFFICIAL (Sign in ink)

7. DATE (MM/DD/YYYY)

8. TYPE OR PRINTED NAME OF STATE OR TRIBAL CEMETERY OFFICIAL

9. TITLE

10. PHONE ((999) 999-9999)

11. EMAIL

VA FORM 40-10232, SEP 2024

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