Fillable Printable VA Form 40-0895-10

VA Form 40-0895-10

OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS

STATE OR TRIBAL GOVERNMENT CONSTRUCTION GRANT

(38 CFR Part 39)

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory authority

for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal government will

comply with all requirements of Part 39. VA may not conduct or sponsor and you are not required to respond to this collection of

information unless it displays a valid OMB number. Respond to this collection is voluntary. Send comments regarding the burden

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

(005R1B), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for a grant

to this address.

CERTIFICATION: I certify that to the best of my knowledge and belief that (1) all Federal requirements outlined in 38 Code of

Federal Regulations Part 39 as they pertain to this State or Tribal Government Cemetery project; (2) assurances outlined in SF 424D;

and (3) all mandatory comments resulting from the design development review by the U.S. Department of Veterans Affairs (VA) have

been incorporated into construction contact(s) for this State or Tribal Government Veterans Cemetery project to be located at:

STATE OR TRIBAL GOVERNMENT CEMETERY PROJECT LOCATED AT: PROJECT FAI (Federal Application Identifier) NO.

NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

SIGNATURE OF AUTHORIZED STATE OR TRIBAL GOVERNMENTOFFICIAL DATE SIGNED (mm/dd/yyyy)

VA FORM

OCT 2010

40-0895-10