NDVA - SFN 62362 MILITARY FUNERAL HONORS STIPEND REQUEST

DECEASED VETERAN'S INFORMATION
Name (Last, First, Middle)*
Branch of Service*
Social Security Number (Last 4)
if known
Date of Birth*

MonthDayYear
Date
Date of Death*

MonthDayYear
Date
Date Honors Performed*

MonthDayYear
Date
Date of Burial

MonthDayYear
Date
Location of Honors (Name of Church, Cemetery, etc.)*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cemetery Name
City
State
ZIP Code

SERVICE ORGANIZATION PERFORMING HONORS
Organization Name and Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number*
Federal Tax Identification (ID) Number*
Both items must apply for payment approval (initial)
I certify that our Veterans Service Organization has not received funds specifically for this honors service from any other source.*
Initials
I certify that funeral honors were conducted in accordance with our Veterans Service Organization’s policies and procedures.*
Initials
Point of Contact (Printed name)*
Signature*

Clear
Date*

MonthDayYear
Date

CONTACT INFORMATION FOR HONORS REQUESTING ENTITY
Individual/Funeral Home/Cemetery*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number
Point of Contact for Funeral Home/Cemetery (Printed Name)*
Procedures for Requesting Military Funeral Honors Stipend

House Bill 1182 authorizes a stipend reimbursement of $50.00 to Congressionally chartered Veterans Service Organizations for assisting with Veteran Military Funeral Honors starting on 1 July 2023.

The form must be fully completed for an organization to request and receive payment. Entries that are not applicable will be filled in with “N/A”.

DECEASED VETERAN'S INFORMATION

1. All fields must be completed. Date of Burial will be left blank if the veteran is not interred

2. Enter “Cremated not interred” in the Cemetery Name block when the veteran is not to be interred.

SERVICE ORGANIZATION PERFORMING HONORS

1. All fields must be completed. Ensure the organization affiliation and post/chapter number are included.

2. The Federal Identification ID Number is required for payment.

3. The military honors team point-of-contact must initial and sign. Signature cannot be dated prior to the date of honors!

CONTACT INFORMATION FOR HONORS REQUESTING ENTITY

1. This is the contact information for the family member, funeral home, etc. that requested military honors.

2. Ensure the point-of-contact for the funeral home or cemetery is entered if individual requestor information is entered.
Supporting documents and/or copy of W-9

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You can also download and submit the ND Substitute W-9 SFN 53656 for electronic payment if your IRS W-9 is not available.
Should be Empty:

DECEASED VETERAN'S INFORMATION

SERVICE ORGANIZATION PERFORMING HONORS

CONTACT INFORMATION FOR HONORS REQUESTING ENTITY