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

Form Approved, OMB No. 2900-0567
Expiration Date: Xxx, 20XX
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)

CERTIFICATION: I certify, to the best of my knowledge, that the decedent has never committed a serious crime, such as murder or other
offense that could have resulted in imprisonment for life, has never been convicted of a serious crime, and has never been convicted of a sexual
offense for which he or she was sentenced to a minimum of life imprisonment.
PENALTY: The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false or for the fraudulent acceptance of any benefit to which you are not entitled.
SIGNATURE OF REQUESTOR

RETURN COMPLETED FORM ALONG WITH A COPY OF THE DISCHARGE DOCUMENTS TO:

Presidential Memorial Certificates (41B3)
National Cemetery Administration
5109 Russell Road
Quantico, VA 22134-3903
VA FORM
SEP 2013

40-0247

Fax To: 1 (800) 455-7143
Or

ALL PREVIOUS VERSIONS OF THIS FORM WILL BE OBSOLETE 60 DAYS FOLLOWING THE DATE OF THIS FORM.