VA40-1330M
Claim for Government Medallion for Placement in a Private Cemetery
VA Form VA40-1330M is the U.S. Department of Veterans Affairs Claim for Government Medallion for Placement in a Private Cemetery. Its General Information Sheet says VA will furnish a medallion for affixing to an existing privately purchased headstone or marker placed at the gravesite of an eligible deceased Veteran who is buried in a private or local Government cemetery. It says the benefit is only for eligible deceased Veterans who served in the Armed Forces on or after April 6, 1917, regardless of their date of death.
The medallion is made of bronze in three sizes, large, medium and small, and each is inscribed with the word VETERAN across the top and the branch of service at the bottom. The PDF is three pages: the General Information Sheet, then the claim in blocks 1 to 27, signed by the applicant and the cemetery official. You can fill out the PDF free in your browser on this page and download the result without an account.
Initial request or replacement, the reason for a replacement (damage, non-receipt, incorrect branch of service or wrong size), the Veteran's name, whether the remains are buried, and whether the grave is marked with a privately purchased permanent and durable marker.
Race or ethnicity and sex, used for statistical purposes only, the Social Security or service number, place of birth, dates of birth and death, and the dates entered and separated from active duty.
Branch of service, an optional Medal of Honor award with documentation, and the size requested: large (M5), medium (M3) or small (M1). The form says one branch is spelled out on the medallion and more than one are abbreviated.
Who the applicant is, the unclaimed remains choice, the applicant's name, mailing address, daytime phone and email, and the number of Presidential Memorial Certificates requested.
The applicant's certification, signature and date, the name and delivery address for the medallion, a daytime phone, the cemetery where the privately purchased headstone, marker, mausoleum or crypt is located, and the cemetery official's signature and date.
The claim says to read it before completing the claim. It shows the three medallion sizes, who is eligible and who can apply, and says to detach and keep it for your records.
Type or print clearly all information except signatures and check one medallion size in block 14. The form says entries of None, Not Applicable or NA will not be accepted.
The cemetery or other responsible official signs and dates blocks 26 and 27 to certify the size is permitted in the cemetery.
The claim asks for copies of military discharge documents and the death certificate. The General Information Sheet lists the DD Form 214 or equivalent, the VA Pre-Need Eligibility Determination letter or other official documents, and says not to send originals.
Sign block 21 and date block 22, then submit through Quick Submit, by mail or by fax. The form says VA will furnish a medallion only upon receipt of a fully completed and signed claim with required supporting documentation.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form says to submit the claim and supporting documents electronically using Quick Submit at https://eauth.va.gov/accessva/, where you are instructed to register during your first sign-on attempt.
NCA FP Evidence Intake Center, PO Box 5237, Janesville, WI 53547.
1-800-455-7143. The form says that if faxing more than one claim, fax each claim package (claim plus supporting documents) individually.
VA ships the medallion without charge to the name and address in Block 23, with affixing adhesives, hardware and instructions. The form says the Government is not responsible for costs of affixing it.
The form lists the Applicant Assistance Unit toll free at 1-800-697-6947, or ask.va.gov. It says no fee should be paid in connection with the preparation of this claim.
The MAR 2025 edition says all previous versions of this form are obsolete. It carries OMB Approved No. 2900-0222, with an expiration date of 09/30/2027.
VA40-1330
92 fields, 5 pages
VA40-0247
23 fields, 1 page
VA40-1330UP
29 fields, 2 pages
VA40-10007
58 fields, 3 pages
21P-530EZ
93 fields, 8 pages
27-2008
26 fields, 3 pages
The General Information Sheet lists who may be an applicant for a medallion, and who else signs the claim.
No tool matches that search.
It claims a bronze Government medallion to affix to an existing privately purchased headstone or marker at the grave of an eligible deceased Veteran buried in a private or local Government cemetery.
The form lists large at 6 3/8 inches wide, 4 3/4 inches high and 1/2 inch deep, medium at 3 3/4 inches wide, 2 7/8 inches high and 1/4 inch deep, and small at 2 inches wide, 1 1/2 inches high and 1/3 inch deep.
Block 5 says there must be a set headstone, mausoleum, or crypt in place to affix the medallion, and asks whether the grave is marked with a privately purchased permanent and durable marker.
The word VETERAN across the top and the branch of service at the bottom. The form says a single branch is spelled out, such as U.S. ARMY, and more than one branch is abbreviated, such as USA or USAF.
The form says VA will furnish a medallion signifying a Veteran's status as a Medal of Honor recipient when it is requested in block 13 with supporting documentation.
The form says the Government is not responsible for costs associated with affixing the medallion to the privately purchased headstone or marker. Adhesives, hardware and instructions come with it.
The form lists Quick Submit at https://eauth.va.gov/accessva/, mail to NCA FP Evidence Intake Center, PO Box 5237, Janesville, WI 53547, or fax to 1-800-455-7143.