VA Form 40-0895-15 Certification of Cemetery Maintained in Accordance with

OMB NUMBER: 2900-0559
Expiration Date: Xxx, 20XX
Respondent Burden: 15 minutes

CERTIFICATION OF CEMETERY MAINTAINED IN ACCORDANCE WITH
NATIONAL CEMETERY ADMINISTRATION STANDARDS
(As required by 38 CFR 39.31 and 39.81)

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory
authority for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal
government complies with the NCA Shrine Standards following receipt of a grant. 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 (005R1B), 810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS
ONLY. Please do not send applications for a grant to this address.
CERTIFICATION STATEMENT: I certify that the below named state or tribal government cemetery, assisted by a Department of
Veterans Affairs grant, will be operated and maintained in accordance with the operational standards and measures of the National
Cemetery Administration.
NAME AND ADDRESS OF STATE OR TRIBAL GOVERNMENT CEMETERY

PROJECT FAI (Federal Application Identifier)
NO.

NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

SIGNATURE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

DATE SIGNED (mm/dd/yyyy)

VA FORM
OCT 2010

40-0895-15