Form VA Form 21P-530EZ Application for Burial Benefits (Under 38 U.S.C. Chapter 23)

NOTICE OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM
FOR BURIAL BENEFITS (UNDER 38 U.S.C., CHAPTER 23)
This notice provides information regarding the evidence necessary to substantiate a claim for:
• Non-service-connected Burial Allowance
• Service-connected Burial Allowance
• Plot or Interment Allowance
• Transportation Reimbursement
• Unclaimed Remains of Veteran
For more information on burial benefits go to https://www.va.gov/burials-memorials/eligibility/.

When to Use this Form
Use this notice and the attached application to submit a claim for any of the above named burial allowances and related burial benefits. This notice informs
you of the evidence necessary to decide your claim. After you submit your claim on the attached application, you will not receive an initial letter regarding
your claim. You do not need to submit another application.
If you are filing a claim for new burial benefits or disagree with
an evaluation decided more than one year ago...
If you disagree with a burial decided within the past year and
have new and relevant evidence OR
If you are filing a supplemental claim (a claim after an initial
claim for the same burial benefit(s) previously decided)...

Please complete and submit VA Form 21P-530EZ, Application for
Burial Benefits
Please complete and submit VA Form 20-0995, Decision Review
Request: Supplemental Claim**

**You may also file a request for a higher-level review or an appeal to the Board of Veterans' Appeals. For additional information on all these different
options, please visit https://benefits.va.gov/benefits/appeals.asp.

Need assistance with completing and filing your claim?
Veteran Service Officers (VSO)
You may wish to contact an accredited Veterans Service Officer to assist you with your application. For a list of accredited Veteran's Service Organizations
go to https://www.benefits.va.gov/vso/. You may also contact your state office of Veteran's Affairs at https://www.va.gov/statedva.htm . To assign a VSO
as your power of attorney for the claims process, submit VA Form 21-22, Appointment of Veteran Service Organization as Claimant Representative.
Private Attorney and Claims Agents
Attorneys and claims agents are available to assist you in completing your application. To verify if your attorney or claims agent is accredited by the
Department of Veterans Affairs at https://www.va.gov/ogc/apps/accreditation/index.asp. To assign a private attorney for the claims process, please submit a
VA Form 21-22a, Appointment of Individual as Claimant's Representative.
Fees for claims: Generally, an accredited attorney or claims agent can ONLY charge claimants a fee after the VA has issued a decision on a claim.
Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be
charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans
Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee
for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has
complied with the applicable power-of-attorney and the fee agreement requirements.

Want to apply electronically?
You can apply for VA burial benefits online at https://www.va.gov/burials-memorials/veterans-burial-allowance .

VA FORM
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21P-530EZ

SUPERSEDES VA FORM 21P-530EZ, OCT 2024

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GENERAL INFORMATION
ELIGIBLE CLAIMANTS (Who Should File A Claim):
Check the appropriate box on the form (Item 14) regarding your relationship to the veteran to certify your correct claimant eligibility.
VA may grant a claim that any eligible person files. Upon death of the veteran, VA will pay the first living person to file a claim of those listed below:
• The veteran's surviving spouse; OR
• The survivor of a legal union between the deceased veteran and the survivor; OR
• The veteran's children, regardless of age (biological, step and adopted); OR
• The veteran's parents or the surviving parent; OR
• The executor or administrator of the deceased veteran's estate, or person acting for the deceased veteran's estate (a person is considered acting for the
estate when no executor or administrator has been appointed). This can include friends of the deceased or family members not otherwise listed.
• For purposes of this application, legal union means a formal relationship between the veteran and the survivor that existed on the date of the veteran's
death, was recognized under the law of the State in which the couple formalized the relationship and was evidenced by the State's issuance of
documentation memorializing the relationship.
If the veteran's remains are unclaimed, VA will pay up to the maximum burial allowance and potentially transportation expenses to the person or entity that
provided burial services for the remains of an unclaimed veteran.
NOTE: Claimant Social Security Number and date of birth are not required when claiming unclaimed remains, or if the claimant is a firm, corporation, or
state agency.
TIME LIMIT FOR FILING A CLAIM: Claims for non-service-connected burial allowance must be filed with VA within 2 years after the date of the
veteran's permanent burial or cremation. If a veteran's discharge was corrected after death to "Under Conditions Other Than Dishonorable," the claim must
be filed within 2 years after the date of correction. There is no time limit for the service-connected burial allowance, plot or interment allowance, nonservice-connected burial allowance based upon VA hospitalization death, or reimbursement of transportation expenses.
BURIAL ALLOWANCE: A one-time benefit payment payable toward the expenses of the funeral and burial of the veteran's remains. Burial includes all
legal methods of disposing of the veteran's remains including, but not limited to, cremation, burial at sea and medical school donation. (See evidence table
for more information.)
PLOT OR INTERMENT ALLOWANCE: A one-time benefit payment payable toward:
(1) The person who incurred expenses for the plot or interment of a veteran who was eligible for burial in a national cemetery, if the actual burial was
not in a national cemetery under the jurisdiction of the United States and non-service-connected the burial allowance is granted; OR
(2) The State Veterans Cemetery for expenses payable if non-service-connected burial allowance is granted and veteran was buried in a State-owned
cemetery or sub-section used solely for the remains of such person or other individuals as authorized within 38 U.S.C. 2303(b)(1) and meets the
eligibility for burial in a national cemetery.
"Plot" means the final disposition site of the remains, whether it is a grave, mausoleum vault, columbarium niche, or similar place.
"Interment" means the burial of casketed remains in the ground or the placement of cremated remains into a columbarium niche.
TRANSPORTATION REIMBURSEMENT: When transportation reimbursement is allowable, VA may pay for expenses relating to the transportation of
the veteran's remains. This includes the pickup and the transportation of the veteran's remains to their final resting place. Claims for transportation
reimbursement benefits must include a statement of account showing itemized transportation charges.
VA may pay transportation reimbursement only when one of the following eligibility requirements are met:
• VA hospitalization death; OR
• the veteran was in receipt of disability compensation at the time of death; OR
• the veteran was in receipt of military retirement in lieu of disability compensation at the time of death; OR
• the veteran was in receipt of pension at the time of death; OR
• the veteran's remains are unclaimed; OR
• service-connected burial allowance granted and burial was in a national or covered veterans cemetery.
NOTE: A covered Veterans cemetery is defined as a Veterans cemetery in which a deceased veteran is eligible to be buried that is owned by a State or is
on trust land owned by, or held in trust for, a tribal organization, and for which the Secretary has made a grant under 38 U.S.C. 2408.
PROOF OF DEATH TO ACCOMPANY CLAIM: Death in a government institution does not need to be proven. In other cases, the claimant must
forward a copy of the public record of death. If the proof of death has previously been furnished to VA, it does not need to be submitted again.
Claims for service-connected burial allowance must include the veteran's cause of death.
RESPONSIBLE FOR (LEGALLY INCURRED) EXPENSES: The claimant (you) have already paid or owe the burial expenses for the benefit being
claimed and is legally the responsible party for the debt. By checking "Yes" in Item 29A on the form, you are certifying that this statement is true. If filing
as an executor of the veteran's estate, by checking "Yes" in Item 29A, you certify that the veteran paid the burial prior to his or her death or funds from the
estate were used as payment.
SERVICE RECORD: Service documents will not be returned. If the veteran was receiving VA benefits, this is not required with your application. A
photocopy of the veteran's DD Form 214, Report of Separation (or equivalent) for all periods of military service will permit prompt processing. You may
request a copy of the DD Form 214 through the National Archives' National Personnel Records Center (NPRC) using SF 180, Request Pertaining to
Military Records, (available at https://www.archives.gov/) or through your local public custodian of records.

VA FORM 21P-530EZ, XXX XXXX

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SUBMITTING A CLAIM
When submitting a claim(s) for Burial Benefits the following information tells you what you need to do and what VA will do during the claim process:
HOW TO SUBMIT A CLAIM: Submit your claim on a VA Form 21P-530EZ, Application for Burial Benefits (attached). Make sure you complete and
sign your application.
WHAT YOU NEED TO DO: The tables beginning below describe the information and evidence you need to submit your claim.

Information and Evidence Needed to Submit a Claim
Please submit a complete signed VA Form 21P-530EZ, Application for Burial Benefits, that includes any required evidence listed in the tables below.
If you know of any evidence not in your possession and want VA to try to get it for you;
You must:
• Complete and sign VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) and VA Form 21-4142a,
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) identifying any private medical records you wish
VA to request for you
• Give VA enough information about other relevant evidence so that we can request it from the person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a fee to provide it, or otherwise cannot get the evidence, VA will notify you and provide
you with an opportunity to submit the information or evidence. It is your responsibility to make sure we receive all requested records that are not in
the possession of a Federal department or agency.
You are strongly encouraged to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to submit the information and evidence necessary to support your claim. If within 30 days,
you do not provide any evidence or do not provide us with the information requested to assist you with obtaining evidence, we may decide your claim
prior to the expiration of the one year period. If we decide the claim before one year from the date we receive the claim, you will still have the remainder
of the one year period to submit additional information or evidence necessary to support the claim.
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM: The table below describes the information and evidence VA will assist you in
obtaining.

Information and Evidence VA will Help You Obtain
VA will:
• Retrieve relevant records from a Federal facility, such as a VA Medical Center, that you adequately identify and authorized VA to obtain.
• Provide a medical examination for you, or get a medical opinion, if we determine it is necessary to decide your claim.
• Make every reasonable effort to obtain relevant records not held by a Federal facility that you adequately identify and authorize VA to obtain. These
may include records from State or local governments and privately held evidence and information you tell us about, such as a private doctor or hospital
records from current or former employers.

WHERE TO SEND INFORMATION AND EVIDENCE: You may send your application and any evidence in support of your claim by using either of
the methods shown in the table below.

MAIL TO
Department of Veterans Affairs
Pension Claims Intake Center
P.O. Box 5365
Janesville, WI 53547-5365

VA FORM 21P-530EZ, XXX XXXX

ONLINE
https://www.va.gov/

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WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM: The tables below show what evidence you must provide and eligibility
information to support your claim for burial benefits.
EVIDENCE TABLES
Non-Service-Connected Burial Allowance
To support a claim for non-service-connected burial allowance, the evidence must show:
• VA received a burial claim for non-service-connected burial allowance no later than two years after the burial or cremation of the veteran; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the estate and is applying
on behalf of the veteran who incurred the expenses; AND
• Verification of veteran's military service (only if veteran was not in receipt of VA benefits at time of death); AND
• At the time of death, the veteran:
• Was in receipt of VA disability compensation or VA pension; OR
• Had a claim pending which would have resulted in entitlement to VA disability compensation or VA pension; OR
• Was entitled to receive VA disability compensation or VA pension but decided to receive military retirement or disability pay in place of VA
disability compensation check.
• Was hospitalized by VA. For the purpose of this burial benefit, VA hospitalization is met, if at the time of death, the veteran:
• Was properly admitted to a VA facility; OR
• Was transferred or admitted to a non-VA facility for hospital care under VA contract; OR
• Was transferred or admitted to a nursing home for nursing home care at the expense of the VA contract; OR
• Was traveling under proper prior authorization to or from a specified place for purpose of examination treatment or care, at VA expense; OR
• Was transferred or admitted to a State nursing home at the expense of the VA, under VA contract; OR
• Was a patient in a State Veteran's home
• Was a patient of VA home hospice if the veteran died between July 1, 2025 and September 30, 2026, if care began immediately after
discharge from VA hospital or nursing home care.
Service-Connected Burial Allowance
To support a claim for service-connected burial allowance, the evidence must show:
• VA received a burial claim for service-connected burial allowance; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death including the cause of death; AND
• Statement certifying that the claimant incurred the burial expenses of the deceased veteran, or claimant is the executor of the estate and is applying
on behalf of the veteran who incurred the expenses; AND
• Verification of the veteran's military service (only if the veteran was not in receipt of VA benefits at the time of death); AND
• If your claim is based on a service-connected disability established during the veteran's lifetime, the evidence must show:
• The veteran had a service-connected disability(ies) that was/were either the principal or contributory cause of the veteran's death; OR
• If your claim is based on a disability that was not established as service-connected during the veteran's lifetime or for which the veteran did not
file a claim during his or her lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active military service, or an event in service that caused an injury or disease;
AND
• A physical or mental disability that was either the principle and contributory cause of death. This may be shown by medical evidence or by
lay evidence of persistent and recurrent symptoms of a disability that were visible or observable; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in military service. Medical records
or medical opinions are generally required to establish this relationship.
Unclaimed Remains
In order to support a claim for unclaimed remains, the evidence must show:
• VA received a burial claim for veteran's unclaimed remains no later than two years after the burial or cremation of the veteran; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred burial expenses of the deceased veteran; AND
• The remains of the deceased veteran have not been claimed by relatives or friends; AND
• There are not sufficient resources available in the veteran's estate to cover the burial and funeral expenses.
NOTE: Funeral homes and/or entities in care and custody of remains who incurred costs for burial of unclaimed veteran remains may file a claim for
burial benefits as the claimant responsible for the expense. When filing a claim, check "Yes" in Items 29A and 29B as the responsible party for the burial
expense if you incurred costs due to the service you provided in burial or cremation of the remains. By checking "Yes", you are certifying that you
incurred the costs and no one other than you is responsible for the expense.
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EVIDENCE TABLES (Continued)
Plot or Interment Allowances
In order to support a claim for plot or interment allowance, the evidence must show:
• VA received a burial claim for plot or interment allowance; AND
• You are an eligible claimant authorized burial benefits; AND
• Veteran's burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred plot or interment expenses, or claimant is the executor of the estate and is applying on behalf of the
veteran who incurred the expenses; AND
• Veteran's burial or interment was not in a National cemetery, State Veterans cemetery or other State-owned cemetery.
Transportation Reimbursement
To support your claim for transportation reimbursement, the evidence must show:
• VA received a burial claim for transportation reimbursement; AND
• You are an eligible claimant authorized burial benefits; AND
• Proof of veteran's death; AND
• Statement certifying that the claimant incurred transportation expenses of the deceased veteran, or claimant is the executor of the estate and is
applying on behalf of the veteran who incurred the expenses; AND
• An itemized receipt or statement, preferably on letterhead that includes the:
• Name of the deceased veteran; AND
• Specific transportation costs incurred; AND
• Date of the services rendered; AND
• Name of the individual who paid the costs.

HOW VA DETERMINES THE EFFECTIVE DATE

Burial benefits are based on the date of the veteran's death and the death date we receive your claim. The veteran's death certificate is relevant evidence
used in determining the effective date of any benefits we award.

DEPARTMENT OF VETERANS AFFAIRS HEADSTONES AND MARKERS

The Department of Veterans Affairs will furnish, upon request, a Government headstone or marker at the expense of the United States for the unmarked
graves of certain individuals eligible for burial in a national cemetery, but not buried there. These individuals may include any veterans with an other than
dishonorable discharge who dies after service or any servicemember who dies on active duty. Certain other individuals may also be eligible for the
headstone or marker. Headstones or Markers for all individuals in a national or post cemetery are furnished automatically without a request from the
family. For additional information on burial benefits go to the web site, https://www.va.gov/burials-memorials/eligibility/. To obtain VA Form 40-1330,
Claim for Standard Government Headstone or Marker, go to www.va.gov/vaforms or contact your local VA regional office. The address of that office can
be found at www.va.gov/directory.

VA FORM 21P-530EZ, XXX XXXX

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OMB Approved No. 2900-0003
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR BURIAL BENEFITS (Under 38 U.S.C. Chapter 23)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 8 before completing the form.
SECTION I - PERSONAL IDENTIFICATION OF VETERAN
NOTE: You can either complete the form online or by hand. If you complete the form online, you may submit it at VA.gov to expedite processing. If you complete the
form by hand, please print the information requested in ink, neatly, and legibly to help process the form.
1. NAME OF THE DECEASED VETERAN (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S DATE OF DEATH (MM/DD/YYYY)

6. VETERAN'S DATE OF BURIAL (MM/DD/YYYY)

4. VA FILE NUMBER (If known)

SECTION II - CLAIMANT'S INFORMATION
7. CLAIMANT'S NAME (First, Middle Initial, Last)

8. CLAIMANT'S SOCIAL SECURITY NUMBER (See instructions for exceptions)

9. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY) (See instructions for exceptions)

10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

ZIP Code/Postal Code

Country

11. TELEPHONE NUMBER (Include Area Code)
International Phone Number (If applicable)
12. E-MAIL ADDRESS

13. CLAIMANT'S RELATIONSHIP TO DECEASED VETERAN (Check one)
SPOUSE OR SURVIVOR OF LEGAL UNION

EXECUTOR/ADMINISTRATOR OF ESTATE OR PERSON ACTING FOR THE ESTATE

CHILD

FUNERAL HOME

PARENT

OTHER RELATIVE OR FRIEND OF THE DECEASED (Non-Executor)

SECTION III - VETERAN'S SERVICE INFORMATION
The following information should be furnished for the periods of the VETERAN'S ACTIVE SERVICE
14. PLEASE LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER (If none, leave blank)

15. DATE INITIALLY ENTERED ACTIVE DUTY

16. FINAL RELEASE DATE FROM ACTIVE DUTY

18. BRANCH OF SERVICE

19. PLACE OF LAST SEPARATION (If known)

(MM/DD/YYYY)

(MM/DD/YYYY)

NAVY

ARMY

AIR FORCE

COAST GUARD

MARINE CORPS

SPACE FORCE

USPHS

NOAA

20A. WAS VETERAN A PRISONER OF WAR?
YES

VA FORM
XXX XXXX

NO

17. SERVICE NUMBER

20B. DATES CONFINEMENT STARTED (MM/DD/YYYY)

20C. DATES CONFINEMENT ENDED (MM/DD/YYYY)

(If "NO," skip to question 21)

21P-530EZ

SUPERSEDES VA FORM 21P-530EZ, OCT 2024.

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VETERAN'S SSN (Pre-populated from Page 6)

SECTION IV - INFORMATION REGARDING FINAL RESTING PLACE
21. PLACE OF BURIAL PLOT, INTERMENT SITE, OR FINAL RESTING PLACE OF DECEASED VETERAN'S REMAINS
CEMETERY/GRAVEYARD

PRIVATE RESIDENCE

MAUSOLEUM/VAULT/TOMB/CRYPT

OTHER (Specify):

22. WAS THE VETERAN BURIED IN A NATIONAL CEMETERY, OR ONE
OWNED BY THE FEDERAL GOVERNMENT?
YES

23. WAS THE VETERAN BURIED IN A CEMETERY OWNED BY THE STATE OR TRIBAL
TRUST LAND?
YES, State Cemetery

NO

(If "YES," provide name of cemetery below):

YES, Tribal Trust

NO

(If "YES," provide name and Zip code of cemetery or Tribal Trust Land below):
NAME:

24A. DID A FEDERAL/STATE GOVERNMENT OR THE VETERAN'S
EMPLOYER CONTRIBUTE TO THE BURIAL?
YES

NO

ZIP CODE:

24B. AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION
$

(If "YES," complete Item 24B)

25. ARE YOU RESPONSIBLE FOR THE VETERAN'S PLOT OR INTERMENT EXPENSES?
NO

YES

SECTION V - CLAIM FOR BURIAL ALLOWANCE
26A. SELECT TYPE OF BURIAL ALLOWANCE YOU ARE CLAIMING

(May apply for more than one)

26B. WHERE DID THE VETERAN'S DEATH OCCUR? (Check one)
NURSING HOME/FACILITY (NOT PAID BY VA) OR VETERANS RESIDENCE)
NURSING HOME/FACILITY (PAID BY VA)*

NON-SERVICE-CONNECTED BURIAL ALLOWANCE

VA MEDICAL CENTER

SERVICE-CONNECTED BURIAL ALLOWANCE

STATE VETERANS FACILITY

UNCLAIMED REMAINS OF THE VETERAN

(If claimed, you must answer questions 26B, 29A & 29B)

OTHER (Specify place in Item 26C)
* Includes VA home hospice if the veteran died between July 1, 2025 and September 30, 2026, if
care began immediately after discharge from VA hospital or nursing home. Please provide veteran's
specific place of death including the name and location of the nursing home.

26C. PROVIDE VETERAN'S PLACE OF DEATH INCLUDING THE NAME AND LOCATION OF NURSING HOME, VA MEDICAL CENTER, STATE VETERANS FACILITY OR
OTHER PLACE*

27A. DID VETERAN PASS AWAY UNDER A VA COVERED HOME HOSPICE CARE BETWEEN JULY 1, 2025 AND SEPTEMBER 30, 2026? (If "NO," skip to Item 29A)
YES

NO

27B. DID VETERAN TRANSFER TO A VA COVERED HOME HOSPICE CARE FROM A NON-VA FACILITY?

YES

NO

28. IF YOU ARE THE DECEASED VETERAN'S SPOUSE, DID YOU PREVIOUSLY RECEIVE A VA BURIAL ALLOWANCE?
29A. ARE YOU RESPONSIBLE FOR THE VETERAN'S BURIAL EXPENSES?

YES

YES

NO

NO

29B. DO YOU CERTIFY THE REMAINS OF THE DECEASED VETERAN HAVE NOT BEEN CLAIMED BY RELATIVES OR FRIENDS AND THERE ARE NOT SUFFICIENT
RESOURCES AVAILABLE IN THE VETERAN'S ESTATE TO COVER THE BURIAL AND FUNERAL EXPENSES? (Required only if claiming unclaimed remains of veteran)
YES

NO

SECTION VI - CLAIM FOR TRANSPORTATION ALLOWANCE
30. ARE YOU RESPONSIBLE FOR THE VETERAN'S TRANSPORTATION EXPENSES FROM THE PLACE OF DEATH TO THE FINAL RESTING PLACE? (If "Yes," you must

include an itemized receipt)
YES

NO

SECTION VII- DIRECT DEPOSIT INFORMATION
The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct deposit,
provide the information requested below. If you do not have a bank account, please visit https://www.benefits.va.gov/benefits/banking.asp. This website provides
information about the Veterans Benefits Banking Program (VBBP) and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you
elect not to enroll, you must contact representatives handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will encourage your participation
in EFT and address questions or concerns you may have.
31A. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where you want your direct deposit sent)

31B. ACCOUNT TYPE
CHECKING

SAVINGS

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT

31C. ROUTING OR TRANSIT NUMBER (Routing number must be 9 digits)

31D. ACCOUNT NUMBER

SECTION VIII - CLAIM CERTIFICATION AND SIGNATURES (MUST COMPLETE)
CLAIMANT CERTIFICATION AND SIGNATURE
I CERTIFY and authorize the release of information. I CERTIFY that the statements in this document are true and complete to the best of my knowledge. I AUTHORIZE any person or entity,
including but not limited to any organization, service provider, employer, or government agency, to give the Department of Veterans Affairs any information about me and the veteran, and I
WAIVE any privilege which makes the information confidential. I CERTIFY I have received the notice attached to this application titled, Application for Burial Benefits, and I CERTIFY I have
enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal facility such as a VA medical center; or , I have no
additional information or evidence to give VA to support my claim.
VA FORM 21P-530EZ, XXX XXXX

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VETERAN'S SSN (Pre-populated from Page 6)
32A. SIGNATURE OF CLAIMANT (REQUIRED) (If signed

32B. PRINTED NAME OF CLAIMANT

32C. DATE SIGNED (MM/DD/YYYY)

33A. FULL PRINTED NAME OF PERSON, FIRM,
CORPORATION, OR STATE AGENCY SIGNING
AS CLAIMANT (If different from Item 8)

33B. FULL PRINTED ADDRESS OF PERSON, FIRM,
CORPORATION, OR STATE AGENCY SIGNING
AS CLAIMANT (If different from Item 8)

33C. OFFICIAL POSITION OF PERSON
SIGNING ON BEHALF OF FIRM,
CORPORATION OR STATE AGENCY

using an "X", complete Section IX) (If signing for a firm,
corporation, or State agency, complete Items 33A, 33B,
& 33C)

SECTION IX - WITNESSES TO SIGNATURE
NOTE: If the claimant signed above using an "X", the signature must be witnessed by two persons to whom the person making the statement and the signatures
and addresses of such witnesses must be shown below.
34A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in
34B. PRINTED NAME OF WITNESS
Item 32A used an "X")
34C. PRINTED ADDRESS OF WITNESS

35A. SIGNATURE OF WITNESS (Physical Signature) (Only sign if the signature in

Item 32A used an "X")

35B. PRINTED NAME OF WITNESS

35C. PRINTED ADDRESS OF WITNESS

SECTION X - ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (REQUIRED ONLY IF ITEM 32A IS BLANK)
I CERTIFY THAT by signing on behalf of the claimant, I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I UNDERSTAND that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand
that VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the
claimant if necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a
certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time stamp;
copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your authority
as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the care of the
claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
36A. ALTERNATE SIGNER SIGNATURE (REQUIRED only if Item 32A is blank) (Physical Signature)

36B. DATE SIGNED (MM/DD/YYYY)

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans
Affairs (VA) only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation,
Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and
necessary to determine maximum benefits under the law and is required to obtain benefits. Information submitted is subject to verification through computer matching
programs with other agencies.
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 2900-0003, and it expires XX/XX/20XX. Public reporting burden for this collection of information
is estimated to average 30 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 vapra@va.gov. Please refer to OMB Control No. 2900-0003 in any
correspondence. Do not send your completed VA Form 21P-530EZ to this email address.

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.

VA FORM 21P-530EZ, XXX XXXX

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