Form VA Form 40-0247 VA Form 40-0247 Presidential Memorial Certificate (PMC)

The President has requested that the enclosed Presidential Memorial Certificate be sent in memory of your beloved, deceased Veteran. If this Certificate contains an error, or arrives in an unacceptable condition, or if you wish additional Certificates (no cost) for other family members, please complete the information areas on the other side of this insert and mail to:

Presidential Memorial Certificates (41A1C)

National Cemetery Administration

5109 Russell Road

Quantico, VA 22134-3903

If you wish to telephone on this matter, please call (202) 565-4964

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 (005G1), 810 Vermont Avenue NW, Washington DC 20420. SEND COMMENTS ONLY. Please do not send applications for benefits to this address.

The veteran’s name only may be shown (no nickname, military rank or civilian title).

The veteran’s name is: ___________________________________________________________

(Please print or type)

Please send_______ additional certificate(s): ________________________________

(Signature of Requestor)

Send the additional certificate(s) to:(Please print or type)

You may photo copy this insert or attach a separate sheet of paper for additional names

and addresses

Please Circle Mr. Mrs. Ms. __________________________________________________

(Name)

____________________________________________________________________

(Street Address)

____________________________________________________________________

(City, State and ZIP Code)

____________________________________________

(Home or Work Telephone No. include area code)

_____________________________________________________

(Today’s Date)

VA Form 40-0247 U.S. Government Printing Office 1998-405-595 Form Approved, OMB No. 2900-0567 Respondent Burden: 2 minutes

Use this only for ordering additional or replacement Certificates

“The National Cemetery Administration does not give, sell or transfer any personal information outside of the agency”.

Respondent Burden: Public reporting burden for this collection of information is estimated to average two minutes per response. Statutory authority for the Presidential Memorial Certificates 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 of friends) to request additional certificates and/or replacement or corrected certificates on receipt of the original PMC.