Form VA40-10190 Form VA40-10190 FUNERAL HONORS PROVIDERS CERTIFICATION FORM

OMB NUMBER: 2900-0865
Expiration Date: Sept. 30, 2022
Respondent Burden: 5 minutes

FUNERAL HONORS PROVIDERS CERTIFICATION FORM
Respondent Burden: Public reporting burden for this collection of information is estimated to average 5 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. This form, when completed will allow VA to permit funeral honors provider
organizations to perform funeral honors activities at VA national cemeteries. 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. 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
(005R1B), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY.
FUNERAL HONORS PROVIDER ORGANIZATION
FUNERAL PROVIDER ORGANIZATION NAME

ADDRESS (Street, City, State, Zip Code)

PHONE NUMBER

E-MAIL

DESIGNATED REPRESENTATIVE'S INFORMATION (Person Authorized to Represent the Funeral Honors Provider Organization)
DESIGNATED REPRESENTATIVE'S NAME

ADDRESS (Street, City, State, Zip Code) (If different than above)

TITLE

PHONE NUMBER

E-MAIL

CERTIFICATION

• I certify that I
activities.

am an authorized representative for the organization performing funeral honors

• I certify that the name and contact information for the funeral honors provider organization and the representative for the organization accountable
for funeral honors listed above is valid.
• I certify that the funeral honors provider organization and its members will comply with VA security, safety, and law enforcement regulations under
38 CFR 1.218 ensuring protection of the decedent family and other cemetery visitors and maintaining the honor and dignity of the national
cemeteries.
• I certify that the funeral honors provider organization and its members will maintain and operate any equipment in a safe manner consistent with
VA and DoD policies.
• I certify that the funeral honors provider organization and its members will not solicit for or accept donations on VA property except as authorized
under 38 CFR 1.218(a)(8).
ADDITIONAL CERTIFICATION FOR NON-DOD FUNERAL HONORS PROVIDER ORGANIZATIONS

• I certify that that the funeral honors provider organization and its members will conduct activities on federal property as an independent entity, not
as an agent or employee of VA, unless registered as a VA volunteer.
• I certify that the funeral honors provider organization and its members conducting funeral honors have completed training on funeral honors tasks
and the safe use of funeral honors equipment.
• I certify that the funeral honors provider organization and its members will provide funeral honors services in accordance with the agreement
between the personal representative of the individual being honored and the funeral honors provider organization.
FUNERAL HONORS PROVIDER REPRESENTATIVE SIGNATURE (Ink Signature Requeired)

VA FORM
SEP 2019

40-10190

DATE (MM/DD/YYYY)