Va Form 40-0895-3 - State Or Tribal Government Cemetery Grants Service Space Program Analysis - Buildings Page 3

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CERTIFICATION: I certify that this accurately reflects the proposed space program analysis for this project.
SIGNATURE OF A & E FIRM REPRESENTATIVE
DATE SIGNED
SIGNATURE OF STATE OR TRIBAL GOVERNMENT PROJECT MANAGER
DATE SIGNED
SIGNATURE OF DESIGNATED STATE OR TRIBAL GOVERNMENT OFFICIAL
DATE SIGNED
SIGNATURE OF STATE CEMETERY GRANTS SERVICE REVIEWER
DATE SIGNED
Respondent Burden: Public reporting burden for this collection of information is estimated to average 3 hours. Statutory authority for a State
Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to provide documentation on the appropriate size of the building, based
on VA guidance on the net and gross square footage standards for cemetery buildings. 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.
VA FORM 40-0895-3, OCT 2010
PAGE 3 OF 3

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