Fillable Commonwealth of Massachusetts Veterans' Bonus Application for Deceased Veteran

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Commonwealth of Massachusetts Veterans' Bonus Application for Deceased Veteran

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The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
VETERANS’ BONUS APPLICATION FOR DECEASED VETERAN
If you are the parent, spouse, or relative of a deceased veteran, the enclosed application is to be filled out as indicated:
1) The applicant must complete Sections A and B and one of the following other Sections pertaining to the relationship with the
deceased veteran: C (Spouse), D (Children), E (Mother or Father), or F (Brother or Sister).
2) The city or town clerk, or election commission must seal and certify residence where the veteran was domiciled prior to entry into
the Armed Forces. (This portion is part of Section A.)
3) Please use the provided checklist to ensure all proper documents are included before sending in the application. These documents
should be copies.
CHECKLIST
The State Treasurer’s Office administers the Veterans’ Bonus for the following wars:
WORLD WAR II KOREAN VIETNAM IRAQ/AFGHANISTAN
Service between:
9/16/40-6/25/47
Service between:
6/25/50-1/31/55
Service between:
7/1/58-5/17/75
Service on or after
9/11/01– present
If you have any questions about this application, please call our office at: (617) 367-9333 ext. 859
(Revised Jan 2015)
SPOUSE CHILDREN
□ Marriage certificate
□ Birth certificate of deceased
□ Death certificate of deceased (if died out of service)
□ All DD214s (if died out of service)
□ DD Form 1300 (if died while in service)
□ Daytime telephone number
□ Marriage certificate of parents
□ Death certificate of deceased’s spouse
□ Birth certificates of all deceased’s children
□ Birth certificate of deceased
□ Death certificate of deceased (if died out of service)
□ All DD214s (if died out of service)
□ DD Form 1300 (if died while in service)
□ Daytime telephone number
MOTHER OR FATHER BROTHER OR SISTER
□ Marriage certificate or Divorce decree
□ Birth certificate of deceased
□ Death certificate of deceased (if died out of service)
□ All DD214s (if died out of service)
□ DD Form 1300 (if died while in service)
□ Daytime telephone number
□ Birth certificates of all deceased’s siblings
□ Marriage certificate of deceased’s parents
□ Birth certificate of deceased
□ Death certificate of deceased (if died out of service)
□ All DD214s (if died out of service)
□ DD Form 1300 (if died while in service)
□ Daytime telephone number
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
SECTION A
(DECEASED VETERAN’S INFORMATION)
ALL answers must be written in ink
1) Name of veteran:
Last First Middle Initial
2) Name at time of death (if different):
Last First Middle Initial
3) Gender: Male □ Female □ 4) SSN: -- 5) D.O.B.: //
6) Branch of Service: 7) Rank/Grade: 8) Serial #:
(if applicable)
9) Enlisted: 10) Inducted
(if applicable):
Date Place Date Place
11) Commissioned (if applicable): 12) Active Duty began:
Date Place Date
13) Date of Discharge: 14) Character of Service:
15) Address at time of entry into service:
Street City/Town State Zip Code
16) Address at time of separation from service:
(if different)
Street City/Town State Zip Code
17) Parents’ names and addresses of deceased at time of entry into service:
Mother:
Name Street City/Town State Zip Code
Father:
Name Street City/Town State Zip Code
18) Spouse’s name and address if deceased was married at time of entry:
Wife or Husband:
Name Street City/Town State Zip Code
_________________________________________________
Applicant’s Signature
(Revised Jan 2015)
(Section A continued on next page)
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The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
CERTIFICATE OF RESIDENCY
(to be completed by a City or Town Official ONLY)
SECTION A (continued)
(DECEASED VETERAN’S INFORMATION)
ALL answers must be written in ink
(A) I hereby certify that according to the official records of this office,
,
(Name of Deceased Veteran)
was a resident of in the Commonwealth of Massachusetts on January first of the year :
City or Town Name
prior to the veteran’s entry into the armed forces of the United States.
(B) If applicant was a minor, certify residency of either father or mother’s name in Section A, box 17.
(C) If you are unable to have the residency certified, please call the Veterans’ Bonus Division in the
SEAL
State Treasurer’s Office: (617) 367-9333 x859.
Signature of City/Town Official Printed Name of Official
SECTION B
(TO BE FILLED OUT BY APPLICANT)
ALL answers must be written in ink
Penalty Provisions, Sec. 8, Ch. 646, Acts of 1968: “Whoever knowingly makes a
false statement, oral or written, relating to material fact supporting a claim under
the provisions of this act, shall be punished by a fine of not more than one
thousand dollars, or by imprisonment for no more than three years, or both…”
Applicant’s Signature
Date
1) Name of applicant:
Last First Middle Initial
2) Address of applicant:
Street City/Town State Zip Code
3) Phone #: () -  4) Applicant’s SSN: --
5) Were you a dependent of the deceased? 6) If “Yes”, check the appropriate box to show what kind of dependant you were.
Yes
□ No □ (a) At time that deceased entered the service: Solely □ Partially □
(b) At time of death of deceased: Solely □ Partially □
7) (a) Were there any other persons dependant upon the deceased? Yes
□ No □
(b) If “Yes”, please fill in the required information about said persons.
(Revised Jan 2015)
NAME RELATIONSHIP
MINOR?
Y OR N
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
SECTION C- SPOUSE
(TO BE FILLED OUT BY SPOUSE OF DECEASED)
A copy of Marriage Certificate must be included
ALL answers must be written in ink
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
(Revised Jan 2015)
NAME ADDRESS DATE OF BIRTH
1) Maiden name of applicant:
(if applicable)
Last First Middle Initial
3) Applicant’s Date of Birth: // 4) Applicant’s Place of Birth:
5) Applicant’s date of marriage to deceased. (Marriage Certificate must be included): 6) Place of marriage:
//
7) (a) Are there any surviving children of the deceased? Yes
□ No □ (b) If “Yes”, please list names, addresses, and dates of birth.
8) (a) Did the deceased leave a surviving mother, father, or both? Yes
□ No □ (b) If “Yes”, please list names and addresses. (If mother, father,
or both deceased, please write “deceased”.)
9) (a) Has the marriage to deceased been dissolved by divorce? Yes
□ No □ (b) If so, a certified copy of decree of court must be included with
this application.
2) Full name of applicant:
Last First Middle Initial
Penalty Provisions, Sec. 8, Ch. 646, Acts of 1968: “Whoever knowingly makes a
false statement, oral or written, relating to material fact supporting a claim under
the provisions of this act, shall be punished by a fine of not more than one thou-
sand dollars, or by imprisonment for no more than three years, or both…”
PARENT NAME ADDRESS
MOTHER:
FATHER:
Applicant’s Signature
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
SECTION D- CHILDREN
(TO BE FILLED OUT BY ELDEST SON/DAUGHTER OF DECEASED)
Copies of all children’s Birth Certificates must be included
ALL answers must be written in ink
2) Applicant’s Date of Birth: // 3) Applicant’s Place of Birth:
4) (a) Name of other parent:
Last First Middle Initial
(b) Address of other parent (if living):
Street City/Town State Zip Code
(c) If not living, state date and place of death. (a copy of Death Certificate must be included.)
Date:  /  /  Place:
4) Please list names and addresses of all surviving children of deceased from present and any previous marriages.
7) If applicant is a minor, write name and address of legal guardian, if any.
Name
Street City/Town State Zip Code
1) Full name of applicant:
Last First Middle Initial
NAME ADDRESS
Penalty Provisions, Sec. 8, Ch. 646, Acts of 1968: “Whoever knowingly makes a false state-
ment, oral or written, relating to material fact supporting a claim under the provisions of this
act, shall be punished by a fine of not more than one thousand dollars, or by imprisonment
for no more than three years, or both…”
Applicant’s Signature
(Revised Jan 2015)
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
(Revised Jan 2015)
SECTION E– PARENT
(TO BE FILLED OUT BY MOTHER/FATHER OF DECEASED)
A copy of Marriage Certificate or Divorce decree of parents & Birth Certificate of deceased must be included
ALL answers must be written in ink
1) Date and place of marriage of applicant:  /  / 
Date Place
2) Date and place of birth of deceased:  /  / 
Date Place
3) Name of other parent of deceased:
Last First Middle Initial
4) If other parent is living, state address of said parent:
Street City/Town State Zip Code
5) If other parent is deceased, state date and place of death. (A copy of Death Certificate must be included.)
 /  / 
Date Place
6) Was the deceased married? Yes □ No □ If “Yes”, please state:
(a) Date and place of most recent marriage:
 /  / 
Date Place
(b) Name of spouse:
Last First Middle Initial
(c) Address of spouse, if living:
Street City/Town State Zip Code
(d) Manner of dissolution of marriage. (Choose one): Divorce □ Death □
(e) Names and addresses of all surviving children of any past and present marriage.
NAME
ADDRESS
Penalty Provisions, Sec. 8, Ch. 646, Acts of 1968: “Whoever knowingly makes a
false statement, oral or written, relating to material fact supporting a claim under
the provisions of this act, shall be punished by a fine of not more than one thou-
sand dollars, or by imprisonment for no more than three years, or both…”
Applicant’s Signature
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
Deborah B. Goldberg
Treasurer and Receiver General
Phone: 617.367.3900 • Office: One Ashburton Place, 12th Floor, Boston, MA 02108-1608 • Web: www.mass.gov/treasury
(Revised Jan 2015)
SECTION F– SIBLING(S)
(TO BE FILLED OUT BY ELDEST SIBLING)
Copies of Birth and Death Certificates of deceased must be included
A copy of applicant’s Birth Certificate must also be included
ALL answers must be written in ink
1) Applicant’s date and place of birth.
(a) DOB: / /  (b) Place:
2) Deceased’s date and place of birth:
(a) DOB: / /  (b) Place:
3) Names and addresses of parents of deceased:
5) If either or both parents are not living, state the date and place of death of such parent(s): (Please include a copy of their Death Certificates)
6) Names and addresses of living siblings of deceased:
PARENT
NAME ADDRESS
MOTHER:
FATHER:
PARENT DATE OF DEATH PLACE OF DEATH
MOTHER:
FATHER:
SIBLINGS NAMES ADDRESSES
BROTHERS:
SISTERS:
Penalty Provisions, Sec. 8, Ch. 646, Acts of 1968: “Whoever knowingly makes a
false statement, oral or written, relating to material fact supporting a claim under
the provisions of this act, shall be punished by a fine of not more than one thou-
sand dollars, or by imprisonment for no more than three years, or both…”
Applicant’s Signature
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Commonwealth of Massachusetts Veterans' Bonus Application for Deceased Veteran

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Completed 11 May 2020

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