You must indicate your relationship to the claimant in Item 34.
34a. Check (A) if you are the claimant
34b. Check (B) and complete Items 35-38 if your are signing for a claimant who has not attained the age of 18 years, is mentally incompetent, or is physically unable to sign the pre-need application. You may be a court-appointed representative, a person who is responsible for the care of the individual (including a spouse or other relative), or an attorney in fact or agent authorized to act on behalf of the claimant under a durable power or attorney. If the claimant is in the care of an institution, a manager or principal officer of the institution may sign the form. Please attach supporting documents or an affidavit establishing your position relative to the claimant.
Privacy Act Information: Title 38 U.S.C. 2402 authorizes the solicitation of this information. VA considers the responses you submit confidential (38 U.S. C. 5701 VA may only disclose this information outside the VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 175VA41A, published in the Federal Register. VA considers the requested information relevant and necessary to determine maximum benefits under the law. The purpose for which the records are used will include, but will not be limited to the provision of VA burial and memorial benefits; provision of information about VA burial and memorial benefits, including specific claims; determination of eligibility for burial in a VA national cemetery; disclosure of military service information upon request from VA funded State and Tribal Veterans cemeteries; coordination of committal services and interment upon request of families, funeral homes, and others of eligible decedents at VA national cemeteries.
Respondent Burden: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate the time expended by individuals who complete this form will average 20 minutes per response, including the time to review instructions, search existing data sources, gather the necessary data, and complete and review the collection of information. Your response is voluntary and not required to obtain or retain benefits to which you may be entitled. Send comments concerning the accuracy of this burden estimate, including suggestion for reducing this burden or any other aspect of this collection of information to the VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. Please DO NOT send claims for, or correspondence regarding benefits to this address.