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

OMB NUMBER: 2900-0865
Expiration Date: Sept. 31, 2025
Respondent Burden: 5 minutes

FUNERAL HONORS PROVIDERS CERTIFICATION 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 2900-0865, and it expires 09/31/2025. Public reporting burden for this collection of
information is estimated to average 5 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 [email protected]. Please refer to OMB Control No.
2900-0865 in any correspondence. Do not send your completed VA Form 40-10190 to this email address.
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, 41VA41 published in the Federal Register.

FUNERAL HONORS PROVIDER ORGANIZATION
ADDRESS (Street, City, State, Zip Code)

FUNERAL PROVIDER ORGANIZATION NAME
PHONE NUMBER ((999) 999-9999):
E-MAIL

DESIGNATED REPRESENTATIVE'S INFORMATION (Person Authorized to Represent the Funeral Honors Provider Organization)
ADDRESS (Street, City, State, Zip Code) (If different than above)

DESIGNATED REPRESENTATIVE'S NAME

TITLE
PHONE NUMBER ((999) 999-9999):

E-MAIL

CERTIFICATION
• I certify that I

am an authorized representative for the organization performing funeral honors activities.

• 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.
• In accordance with 38 CFR 38.619, I certify to all the following:
• 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's family and other cemetery visitors and maintaining the honor and dignity of the national
cemeteries.
• 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 and regulations.
• 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
• In accordance with 38 CFR 38.619, I certify to all the following:
• 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.
• 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.
• 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 (Digital or Ink Signature Required)

VA FORM
MAY 2025

40-10190

DATE (MM/DD/YYYY)