VA 40-0895-10 Certification of Compliance

OMB NUMBER: 2900-XXXX
Respondent Burden: 15 minutes

CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS
STATE OR TRIBAL GOVERNMENT CONSTRUCTION GRANT
(38 CFR Part 39)
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 will
comply with all requirements of Part 39. 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: I certify that to the best of my knowledge and belief that (1) all Federal requirements outlined in 38 Code of
Federal Regulations Part 39 as they pertain to this State or Tribal Government Cemetery project; (2) assurances outlined in SF 424D;
and (3) all mandatory comments resulting from the design development review by the U.S. Department of Veterans Affairs (VA) have
been incorporated into construction contact(s) for this State or Tribal Government Veterans Cemetery project to be located at:
STATE OR TRIBAL GOVERNMENT CEMETERY PROJECT LOCATED AT:

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 GOVERNMENTOFFICIAL

DATE SIGNED (mm/dd/yyyy)

VA FORM
MAR 2010

40-0895-10

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