Fillable Printable VA Form 40-0895-2

VA Form 40-0895-2

OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION OF COMPLIANCE

WITH PROVISIONS OF THE DAVIS-BACON ACT

(40 U.S.C. 3141 - 3148)

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 pays the prevailing wage rates

for this Federally funded project. 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 STATEMENT: I certify that I have obtained the latest prevailing wage rates from the U.S. Department of

Labor for the State or Tribal Government Cemetery project and have incorporated them into the construction contract in compliance

with the Davis-Bacon Act.

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 GOVERNMENT OFFICIAL DATE SIGNED (mm/dd/yyyy)

VA FORM

OCT 2010

40-0895-2