GENERAL INFORMATION SHEET
CLAIM FOR STANDARD GOVERNMENT HEADSTONE OR MARKER
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 claims for benefits to this address.
a. HEADSTONE OR MARKER
Only for Veterans who died on or after November 1, 1990 - Furnished for the grave of any eligible deceased Veteran. Will be provided for
placement in private cemeteries regardless of whether or not the grave is already marked with a privately-purchased headstone or marker.
Only for Veterans who died before November 1, 1990 - Furnished for the UNMARKED GRAVE of any eligible deceased Veteran. The
applicant must certify the grave is unmarked. For Veterans that served prior to World War I, a grave is considered marked when a
headstone/marker displays the decedent's name only, or if the name was historically documented in a related document, such as by a
number that is inscribed on a grave block and is recorded in a burial ledger. For service during and after World War I, a grave is
considered marked if a headstone/marker displays the decedent's name and date of birth and/or death, even though the Veteran's military
data is not shown.
b. MEMORIAL HEADSTONE OR MARKER - Furnished for placement in a cemetery only to commemorate a deceased eligible Veteran
whose remains have not been recovered or identified, were buried at sea, donated to science, or cremated and the remains scattered. May not be
used as a memento. Check box in block 28 and explain in block 27.
c. MEDALLION - Eligible Veterans may receive a Government-furnished headstone or marker, or a medallion, but not both. If requesting a
medallion, please use VA Form 40-1330M.
WHO IS ELIGIBLE - Any deceased Veteran discharged under honorable conditions and any member of the Armed Forces of the United States who dies on
active duty. A deceased Veteran discharged under conditions other than honorable 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. Service prior to World War I requires detailed documentation, e.g., muster rolls,
extracts from State files, military or State organization where served, pension or land warrant, etc.
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, i.e.,
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 Government headstone or marker may be furnished only upon receipt of a fully completed and signed claim with required supporting documentation.
SIGNATURES REQUIRED - The applicant signs in block 17; the person agreeing to accept delivery (consignee) in block 22, and the cemetery or other
responsible official in block 24. If there is no official on duty at the cemetery, the signature of the person responsible for the property listed in block 21 is
required. Entries of "None," "Not Applicable," or "NA" cannot be accepted. State Veterans' Cemeteries are not required to complete blocks 17, 18, 22 and
ASSISTANCE NEEDED - If assistance is needed to complete this claim, contact the nearest VA Regional Office, national cemetery, or a local veterans'
organization. No fee should be paid in connection with the preparation of this claim. Use block 27 for any clarification or other information you wish to
provide. Should you have questions when filling out this form, you may contact our Applicant Assistance Unit toll free at: 1-800-697-6947, or via e-mail at
TRANSPORTATION AND DELIVERY OF MARKER - The headstone or marker is shipped without charge to the consignee designated in block 19 of
the claim. The delivery will not be made to a Post Office box. The consignee should be a business with full delivery address and telephone number. If the
consignee is not a business explain fully in block 27. For delivery to a Rural Route address, you must include a daytime telephone number including area
code in block 20. If you fail to include the required address and telephone number information, we cannot deliver the marker. The Government is not
responsible for costs to install the headstone or marker in private cemeteries.
CAUTION - To avoid delays in the production and delivery of the headstone or marker, please check carefully to be sure you have accurately furnished all
required information before faxing or mailing the claim. If inaccurate information is furnished, it may result in an incorrectly inscribed headstone or
marker. Headstones and markers furnished remain the property of the United States Government and may not be used for any purpose other than to be
placed at an eligible individual's grave or in a memorial section within a cemetery.
DETACH AND RETAIN THIS GENERAL INFORMATION SHEET FOR YOUR RECORDS.
ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE ON OCTOBER 1, 2014