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

OMB Number 2900-0567

Respondent Burden: 2 minutes

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

Our toll free fax line is 1-800-455-7143

or;

Our mailing address is;

Presidential Memorial Certificates (41A1C)

National Cemetery Administration

5109 Russell Road

Quantico, VA 22134-3903

If you would like assistance with filling out this form, please call (202) 565-4964. Please be advised that this is not a toll free number. Please do not call this number to order additional or corrected copies or to confirm receipt of your faxed request. Fax reports can be generated on the senders fax machine.

Respondent Burden: Public reporting burden for this collection of information is estimated to average 2 minutes. Statutory authority for the Presidential Memorial Certificated is 38 U.S.C. 112. The information requested is necessary to allow eligible recipients (next of kin, other relatives or friends to request additional certificated and/or replacement or corrected certificates on receipt of other original PMC. VA may not conduct or sponsor and you are not required to respond to this collection of information unless it displays a valid OMB number. Respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspects of this collection of information, including suggestions for reducing the burden to VA Clearance Officer (005R1), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for benefits to this address.

REQUEST FOR ADDITIONAL OR CORRECTED COPIES

PLEASE ONLY USE THIS FORM FOR REQUESTS FOR ADDITIONAL COPIES OR TO REQUEST A CORRECTION TO A PMC THAT HAS ALREADY BEEN RECEIVED.

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

The veteran’s name is: __________________________________________________

(Please Print the Veterans Name Here, there is a limit of 27 characters & spaces)

Please send ________ additional/corrected certificate(s): _____________________________

(Please circle one) (Signature of Requestor)

Send the additional certificate(s) to the address listed below. Please print or type the name and addresses in the space below. Please do not attach or send a list of names & addresses. You may photo copy and return this form as many times as you need. There are no charges for additional copies and there is no time limit for when a request can be made. You do not need to send discharge documents again. Please remember to sign this request in the space above. Forms received without signatures or phone numbers will delay the timely delivery of your PMC while we attempt to contact you to verify your request.

Please circle: Mr. Mrs. Ms. ________________________________________________

(Please Print Name Here)

______________________________________________________________________

(Please Print Street Address or Mailing Address Here)

______________________________________________________________________

(Please Print City, State, and Zip Code Here)

____________________________________________

(Please Print Home or Work Telephone Number Here)

___________________________________________

(Please Print the Date of this request Here)

PLEASE DO NOT USE THIS FORM FOR “NEW” ORDERS.

We encourage you to return this form to us via fax to our toll free fax line at 1-800-455-7143 when you have completed and signed it. This fax is toll free to the sender. Please fax only 1 page at a time hanging up between each fax. Multiple requests in a single fax will delay the processing of your request and may result in one or more of the requests not being processed.

PMC Original Insert Form 40-0247