Application for Gold Star Parent Annuity
New York State Executive Law 367
Gold Star Parent Definition
To qualify as a Gold Star Parent, the applicant
must be the parent of a Servicemember who
died inside a combat zone. For criteria, please
see 10 U.S.C. §1126.
Applicant’s Full Name:
MIFirst Name
Applicant’s Actual Address:
Address 1
Address 2
City State Zip Code
Applicant’s Telephone # Applicant’s Social Security #Applicant’s Email Address
Relationship to Deceased Veteran
Is any other individual
eligible to receive this
benefit?
Y
es
No
If Yes, provide their name, address &
social security #:
Are you or any other eligible applicant currently incarcerated? Yes No
Deceased Veteran’s Full Name:
Last Name
MIFirst Name
Deceased Veteran Information:
Date of Birth
Date of Death Place of Death
I certify that the above statements are true and
complete; and I make these statements with the
knowledge that willfully issuing a false or fraudulent
statement is a misdemeanor under section 210.45 of
the Penal Law.
Signature
Date
Include the following documentation
with this application:
Send the completed application with
documentation to:
NYS
Department of Veterans' Services
c/o Gold Star Parent Annuity
#2 Empire State Plaza, 17th Fl
Albany, NY 12223
Last Name
Report of Casualty
Proof of NYS
S.S. or Service #
Branch of Service
Grade/Rank
U.S. Dept. of Veterans
Affairs File #
