Form Approved, OMB No. 2900-0567 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)
SIGNATURE OF REQUESTOR
RETURN COMPLETED FORM ALONG WITH A COPY OF THE DISCHARGE DOCUMENTS TO:
Presidential Memorial Certificates (41A1C) National Cemetery Administration 5109 Russell Road Quantico, VA 22134-3903
VA FORM JUN 2007 (R)
Fax To: 1 (800) 455-7143 Or
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