Fillable Printable VA Form 40-0247

VA Form 40-0247

Form Approved, OMB No. 2900-0567

Expiration Date: July, 2017

Respondent Burden: 2 Minutes

PRESIDENTIAL MEMORIAL CERTIFICATE REQUEST FORM

RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average two minutes per response. Statutory authority for

the Presidential Memorial Certificate (PMC) Program is 38 U.S.C. 112. The information requested is approved under OMB Control Number 2900-0567, and is

necessary to allow eligible recipients (next of kin, other relatives or friends) to request additional certificates and/or replacement or correct certificates on receipt of

the original PMC.

The National Cemetery Administration does not give, sell or transfer any personal information outside of the agency. VA may not conduct or sponsor, and you are

not required to respond to this collection of information unless it displays a valid OMB Control Number. Responding to this collection is voluntary. Send

comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to VA Clearance

Officer (005G2), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for benefits to this address.

INSTRUCTIONS: When inserting the veterans name below, DO NOT include nickname, military rank, or civilian title. Complete a new

VA Form 40-0247 for each additional name and/or mailing address.

NAME OF VETERAN NAME AND MAILING ADDRESS OF PERSON REQUESTING CERTIFICATE

NUMBER OF CERTIFICATES

REQUESTED

HOME OR WORK TELEPHONE NUMBER

(Include area code and do not insert spaces between numbers)

CERTIFICATION: I certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder or other

offense that could have resulted in imprisonment for life, has never been convicted of a serious crime, and has never been convicted of a sexual

offense for which he or she was sentenced to a minimum of life imprisonment.

PENALTY: The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any statement or

evidence of a material fact, knowing it to be false or for the fraudulent acceptance of any benefit to which you are not entitled.

SIGNATURE OF REQUESTOR

MILITARY DOCUMENTS MUST BE RETURNED WITH THIS FORM. PLEASE SEND THE DOCUMENTS AND SIGNED FORM TO:

Presidential Memorial Certificates (41B3)

National Cemetery Administration

5109 Russell Road

Quantico, VA 22134-3903

Fax To: 1 (800) 455-7143

VA FORM

AUG 2014

40-0247

ALL VERSIONS OF THIS FORM DATED BEFORE MAY 2013 WILL NOT BE ACCEPTED OR PROCESSED.