FL 40-40 Gravesite Reservation Questionnaire (2 Year)

DEPARTMENT OF VETERANS AFFAIRS

.

You are receiving this letter because
, referred to in this letter as the Reservation Holder,
has a reserved gravesite in
, at Gravesite
in Section
. The
only person authorized to use this gravesite is the Reservation Holder. The National Cemetery Administration (NCA) is required to
keep an accurate account of reserved gravesites and to make them available to other individuals if the Reservation Holder no longer
needs the gravesite.
Please complete the attached Gravesite Reservation Questionnaire by providing the following information:
-If you are replying on behalf of a Reservation Holder who is incapacitated, please indicate that in Block 5.
-If NCA did not send this letter to the Reservation Holder's current mailing address, please provide an updated address in Block 6.
-Mark your intent to keep or relenquish the reserved gravesite in Block 7.
-If you are replying on behalf of a Reservation Holder because they are deceased, please indicate that in Block 8.
Once you have completed the form – to include signing and dating it in Blocks 10 and 11 – please detach and return it using
the postage-paid envelope so that NCA can update its records. If you do not reply, NCA may cancel the reservation. Thank
you for your prompt response.
NOTE: Prior versions of this letter indicated that remarried spouses were not eligible for burial. However, in 2003 the law
changed. Surviving spouses who remarried and whose date of death is on or after January 1, 2000, are eligible for burial in any
VA national cemetery.
Contact the national cemetery listed above if you have questions. Contact information for Department of Veterans
Affairs national cemeteries is available online at https://www.cem.va.gov/cem/cems/allnational.asp .
FL 40-40
NOV 2020 (RS)

DETACH HERE
OMB No. 2900-0546
Expiration Date: Nov. 30, 2023
Respondent Burden: 10 minutes

GRAVESITE RESERVATION QUESTIONNAIRE (2 YEAR)
1. NAME

2. SSN/C/SERVICE NO.

3. SECTION

4. GRAVE

IF YOUR ADDRESS CHANGED, INDICATE THE CURRENT ADDRESS BELOW IN BLOCK 6.
5. ADDITIONAL INFORMATION

6. ADDRESS (Street, City, State and Zip Code)

I AM THE INDIVIDUAL LISTED IN BLOCK 1.
I AM REPLYING ON BEHALF OF THE INDIVIDUAL LISTED IN BLOCK 1.
MY RELATIONSHIP TO THE INDIVIDUAL LISTED IN BLOCK 1 IS:
(Spouse, Child, Aunt, Friend, etc.)
7. PLEASE CHECK THE APPROPRIATE BOX BELOW
YES, I WISH TO RETAIN THE RESERVED GRAVESITE
NO, I DO NOT WISH TO RETAIN THE RESERVED GRAVESITE
9. PRINT NAME
FL 40-40
SEP 2023 (RS)

10. SIGNATURE

8. IS THE INDIVIDUAL IN BLOCK 1 DECEASED? (If yes, what is the
disposition of remains (scattered, buried in a private cemetery, etc.)
YES
NO
11. DATE

12. PHONE NUMBER (Include Area Code)

VA may not conduct or sponsor, and you are not required to respond to this form letter 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 questionnaire 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 reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. 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 OIRA Desk Officer for VA, 725
17th St NW, Washington, DC 20503. SEND COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUEST FOR
BENEFITS TO THIS ADDRESS.
BACK OF FL 40-40, SEP 2023 (RS)