Form VA40-0247 Presidential Memorial Certificate Request Form

OMB Approved No. 2900-0567
Respondent Burden: 3 Minutes
Expiration Date: 08/31/2026

PRESIDENTIAL MEMORIAL CERTIFICATE REQUEST FORM
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0567, and it expires 08/31/2026. Statutory authority for the Presidential Memorial Certificate
(PMC) Program is 38 U.S.C. 112. Public reporting burden for this collection of information is estimated to average 3 minutes per respondent, per year, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0567 in any correspondence. Do not send your completed VA Form 40-0247 to this
email address.

SECTION I - INSTRUCTIONS FOR COMPLETING VA FORM 40-0247,
PRESIDENTIAL MEMORIAL CERTIFICATE REQUEST FORM
Military/Discharge Documents: VA recommends that you attach photocopies of readily available supporting documents so that we can make the determination quickly.
Documents may include the most recent discharge document (DD Form 214) showing active duty service records other than for training purposes, or active duty for a
minimum of 24 continuous months for enlisted Servicemembers after September 7, 1980; for officers, after October 16, 1981, or the full period for which the person was
called to active duty. If you are unable to locate copies of military records, apply anyway, as VA will attempt to obtain records necessary to make a determination.
Name of Veteran: DO NOT include nicknames, military rank or civilian title(s).
Name and Mailing Address of Person Requesting Certificate: Provide the full name and complete mailing address to avoid delays in delivery.
We strongly recommend you download this form online (http://www.cem.va.gov/pmc.asp), complete, sign, and electronically submit it.
For replacement Presidential Memorial Certificates, select the REPLACEMENT check box in 12. Type of Request and complete SECTION II - VETERAN/
SERVICEMEMBER INFORMATION.
Complete a new VA Form 40-0247 for each additional address where certificates will be mailed to.
Privacy Act Information: VA considers the responses you submit confidential (38 U.S.C. 5701). VA may only disclose this information outside the VA if the

disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 175VA41A published in the Federal Register.

SECTION II - VETERAN/SERVICEMEMBER INFORMATION
1. NAME OF VETERAN (First, Middle, Last)

2. VETERAN SSN OR SERVICE NUMBER OR VA FILE NUMBER (Required)

3. RACE OR ETHNICITY (You may select more than one. Information will be used for statistical purposes only.)
AMERICAN INDIAN OR ALASKA NATIVE

ASIAN OR ASIAN AMERICAN

BLACK OR AFRICAN AMERICAN

HISPANIC OR LATINO

NOT HISPANIC OR LATINO

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

4. SEX (Optional. Information will be used for statistical purposes only.)
FEMALE

5. DATE OF BIRTH (MM/DD/YYYY)

WHITE

6. DATE OF DEATH (MM/DD/YYYY)

MALE

SECTION III - PERSON REQUESTING CERTIFICATE INFORMATION
7. NAME OF PERSON REQUESTING CERTIFICATE

8. MAILING ADDRESS OF PERSON REQUESTING CERTIFICATE

9. HOME OR WORK TELEPHONE NUMBER (Include area code) ((999) 999-9999)
10. REQUESTOR EMAIL ADDRESS

11. NUMBER OF CERTIFICATES REQUESTED

12. TYPE OF REQUEST
INITIAL REQUEST (First Time)
REPLACEMENT, REORDER, ADDITIONAL

SECTION IV - CERTIFICATION AND SIGNATURE
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 the decedent was sentenced to a
minimum of life imprisonment.
13. SIGNATURE OF PERSON REQUESTING CERTIFICATE (Required)

SECTION V - SUBMITTING FORM AND DOCUMENTS
ELECTRONICALLY submit your claim and supporting
documents by using Quick Submit at access.va.gov. You will
be instructed to register during your first sign-on attempt.

OR

MAIL your claim and supporting documents to:
NCA FP Evidence Intake Center PO Box 5237
Janesville, WI 53547

OR

FAX claim and supporting
documents to:
1 (800) 455-7143

(The blocks below are for official use only)
14. CASE MANAGER NAME

VA FORM
MAR 2025

40-0247

15. PMC ID NUMBER

16. CASE MANAGER EMAIL

ALL VERSIONS OF THIS FORM DATED BEFORE MAY 2013 WILL NOT BE ACCEPTED OR PROCESSED.