Presidential Memorial Certificate Request Form (Va Form 40-0247)

Form Approved, OMB No. 2900-0567

Respondent Burden: 2 Minutes

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Department of Veterans Affairs

PRESIDENTIAL MEMORIAL CERTIFICATE REQUEST FORM

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

the Presidential Memorial Certificate (PMC) Program is 38 USC 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 ofinfonnation 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 (005U2), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications jar benefits to this address.

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

V A 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

SIGNATUREOF REQUESTOR

HOME OR WORKTELEPHONE NUMBER

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

RETURN COMPLETED FORM ALONG WITH A COPY OF THE DISCHARGE DOCUMENTS TO:

Presidential Memorial Certificates (41A 1 C)

Fax To: 1 (800) 455-7143

National Cemetery Administration

Or

5109 Russell Road

Quantico, VA 22134-3903

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40-0247