Form FL-40-40 Gravesite Reservation Survey (2 year)

DEPARTMENT OF VETERANS AFFAIRS

.

A gravesite is reserved for you in,

in Section,

Grave

.

To keep our records current, please:
1. Furnish requested information on the bottom portion of this letter.
2. Detach the portion containing your completed information and mail it, within 10 days, in the enclosed window
envelope, to the national cemetery listed on the reverse.
We will survey you again in two years.
Cemetery Director
Enclosure
VA may not conduct or sponsor, and you are not required to respond to this survey unless it displays a valid OMB Control Number
2900-0546. Chapter 24, Title 38, United States Code allows VA to determine if individuals holding gravesite reservations in national
cemeteries wish to retain the reservation and whether their eligibility for the reservation has been affected. Responding to this survey is
required to retain your benefit; failure to provide the information may result in cancellation of the gravesite reservation. The information
you provide may be disclosed outside VA as permitted by law or as stated in the "Notices of Systems of VA Records" published in the
Federal Register in accordance with the Privacy Act of 1974 as "Veterans and Dependents National Cemetery Interment Records
VA" (42VA41).
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average 10 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the VA Clearance Officer (045A4), 810 Vermont Avenue, NW,
Washington, D.C., 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR BENEFITS TO THIS
ADDRESS.
FL 40-40
JUN 1999 (RS)

DETACH HERE
Form Approved, OMB No. 2900-0546
Respondent Burden: 10 minutes
SSN/C/SERVICE NO.

SECTION

GRAVE

GRAVESITE RESERVATION SURVEY (2 YEAR)

1. Is the address shown above your correct address?
NAME

YES

NO (If "NO," please provide your new address below.)

STREET

CITY

APT
STATE

2. Do you wish to keep the gravesite that has been reserved? (Check one)
(If you checked "YES," please check the appropriate box below:)
I am the veteran and wish to keep the gravesite that has been reserved.

YES

ZIP CODE

NO

I am the unremarried widow/widower of the veteran and wish to keep the gravesite.
I was the spouse of the veteran, but I have remarried. (If checked, we will send you a follow-up letter.)
I am a dependent of the veteran and wish to keep the gravesite.
FL 40-40
JUN 1999 (RS)