Form Approved OMB No. 2900-0365
Respondent Burden: 10 minutes
DISINTERMENT AFFIDAVIT
PRIVACY ACT NOTICE: The information requested is required to authorize disinterment of remains from a national cemetery under Chapter 24, Title
38, United States Code. The information may be disclosed outside VA as permitted by law, or as stated in the "Notices of Systems of VA Records" which
have been published in the Federal Register in accordance with the Privacy Act of 1974. The disinterment will not be permitted unless the data or a court
order is submitted.
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average ten minutes per response including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. This form, when completed in accordance with VA disinterment regulations, will permit VA to authorize disinterment. This form is approved
under OMB No. 2900-0365. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not
send applications for benefits to this address.
TO WHOM IT MAY CONCERN:
I (we) the undersigned hereby signify my (our) agreement to the disinterment of the remains of
____________________________________________________________________________________ from the __________________________________
__________________________________________________________________ National Cemetery.
RELATIONSHIP
SIGNATURE
ADDRESS
TO DECEASED
Sworn to and subscribed before me this __________ day of _____________________________, 20 ___
[SEAL]
(Notary Public)
My commission expires ________________________________________________
40-4970
VA FORM
SUPERSEDES VA FORM 40-4970, MAR 1997,
Page 2 of 2
JUL 2010(RS)
WHICH WILL NOT BE USED.