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This version of the form is not currently in use and is provided for reference only. Download this version of
VA Form 40-1330M
for the current year.
VA Form 40-1330M Claim for Government Medallion for Placement in a Private Cemetery
What Is VA Form 40-1330M?
VA Form 40-1330M, Claim for Government Medallion for Placement in a Private Cemetery , is a form used to request a government-provided medallion for the deceased veteran. This form should be completed by the authorized person or a next of kin of the deceased. This form can be completed in regard to any deceased veteran discharged under honorable conditions and any member of the US Army who dies on active duty.
The latest version of the form was released by the U.S. Department of Veterans Affairs (VA) on December 1, 2017 , with the existing stock of previous editions used. A fillable VA Form 40-1330M is available for download below or can be found through the VA website.
VA Form 40-1330, Claim For Standard Government Headstone or Marker, is a related form used for requesting a headstone or a marker from the VA. All veterans are entitled to either a traditional headstone, marker, or medallion.
How to Fill Out VA Form 40-1330M?
VA Form 40-1330M instructions are as follows:
- Provide your personal information. Include your full name, phone number, fax number, and the total number of pages,
- Mark Box 1 if the VA previously determined eligibility for burial at a VA State Cemetery. Enter the name of the deceased to be inscribed on the medallion in Box 2. Indicate if the veteran's grave is unmarked in Box 3. Specify the race and gender of the deceased in Boxes 4 and 5. Give the age at the time of death in Box 6.
- Enter the veteran's social security number and service number in Box 7 and their place of birth in Box 8. Give their date of birth and death in Box 9. Provide information about the veteran's periods of active military service in Box 10. Give their branch of service in Box 11.
- Indicate the size of the requested medallion in Box 12. Type your relationship with the deceased in Box 13. Provide your name, phone number, and email address in Boxes 14 through 16. If a presidential memorial certificate is required, mark it in Box 17, and the amount of the certificates in Box 18.
- Sign in Box 19 and date the form in Box 20. Box 21 requires the name of the person that will receive the medallion and delivery address. Enter the phone number of this person in Box 22. Give the name and address of the cemetery where the medallion will be placed in Box 23. Box 24 is for the signature of the cemetery official of the place of burial and Box 25 is for the date of signing the form.
Download VA Form 40-1330M Claim for Government Medallion for Placement in a Private Cemetery
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