VA Form 21P-4718a "Certificate of Balance on Deposit and Authorization to Disclose Financial Records"

VA Form 21P-4718a or the "Certificate Of Balance On Deposit And Authorization To Disclose Financial Records" is a form issued by the United States Department of Veterans Affairs.

The form was last revised on July 1, 2016 - an up-to-date fillable PDF VA Form 21P-4718a down below or find it on the Veterans Affairs Forms website.

ADVERTISEMENT

Download VA Form 21P-4718a "Certificate of Balance on Deposit and Authorization to Disclose Financial Records"

987 times
Rate
(4.4 / 5) 58 votes
OMB Control No. 2900-0017
Respondent Burden: 3 Minutes
Expiration Date: 07/31/2019
CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS
(Pursuant to Title 38, U.S.C., Chapter 55 and Title 12, U.S.C., Chapter 35)
NOTE: PLEASE READ THE INSTRUCTIONS ON THE REVERSE BEFORE COMPLETING THE FORM.
I. CERTIFICATE - TO BE COMPLETED BY THE FINANCIAL INSTITUTION ONLY
(SEAL OR STAMP OF FINANCIAL INSTITUTION)
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any
source other than what has been authorized by the Privacy Act of 1974 or Title 5 Code of Federal
Regulations 1.526 for routine uses (i.e. request from Congressman on behalf of a beneficiary) as
identified in the VA system of records, 37VA27, VA Supervised Fiduciary/Beneficiary Records - VA,
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The
information will be used by VA field examiners to determine whether an individual fiduciary is properly
using and maintaining an accounting of the VA beneficiary's compensation or pension payments. Failure
to furnish the requested information may result in the suspension of payments and/or appointment of a
successor fiduciary.
RESPONDENT BURDEN: We need this information to ensure proper administration of the
beneficiary's estate. Title 38, United States Code, Chapter 55 allows us to ask for this information. We
estimate that you will need an average of 3 minutes to review the instructions, find the information, and
complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB
control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at: www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
(First, middle, last)
(First, middle, last)
3. VA FILE NUMBER
1. NAME OF FIDUCIARY
2. NAME OF BENEFICIARY
C-
4A. NAME OF FINANCIAL INSTITUTION
4B. ADDRESS OF FINANCIAL INSTITUTION
(Include Area Code)
4C. NAME AND TELEPHONE NUMBER OF FINANCIAL INSTITUTION CONTACT PERSON
5. DATA IN ITEM 6 WAS ACCURATE AS OF
(Mo., day, yr.)
6. ACCOUNT INFORMATION
INTEREST EARNED/PAID SINCE
ACCOUNT NUMBER
BALANCE
TYPE OF
DEPOSITOR ACCOUNT
CURRENT
(State "None" if appropriate)
(Include interest earned)
ACCOUNT
TITLE
INTEREST RATE
AMOUNT
DATE
(A)
(C)
(G)
(B)
(D)
(E)
(F)
I CERTIFY THAT the foregoing amount(s) were on deposit to the credit of the above named fiduciary as shown by the record(s) of this financial institution.
7A. SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL
7B. TITLE OF CERTIFYING OFFICIAL
7C. DATE SIGNED
II. AUTHORIZATION - TO BE COMPLETED BY THE FIDUCIARY ONLY
I hereby authorize the financial institution named above to verify the above Certificate information to VA, and/or to provide copies of any of the
financial records described above to VA.
8. I UNDERSTAND THAT:
a. This authorization is not required as a condition of doing business with any financial institution.
b. I have the right to obtain a copy of the record kept by the financial institution when financial records are disclosed as a result of this authorization.
VA has the right to request a court order to delay my receipt of a copy of the record.
c. VA is seeking disclosure of this information under the authority of Title 38 U.S.C. 5502(b) and will use the information in conducting an audit of
estates maintained on behalf of VA beneficiaries.
d. Transfer of records to other agencies of the federal government may only be made in accordance with the provisions of
title 12 U.S.C. 3412.
e. I have the right to withhold my consent to this disclosure.
f. I have the right to seek damages, attorneys' fees, and costs for any violation of the right to financial privacy act by either VA or the financial
institution.
9A. SIGNATURE OF FIDUCIARY
9B. DATE SIGNED
VA FORM
21P-4718a
SUPERSEDES VA FORM 21-4718a, FEB 2009,
Continued on Reverse
JUL 2016
WHICH WILL NOT BE USED.
OMB Control No. 2900-0017
Respondent Burden: 3 Minutes
Expiration Date: 07/31/2019
CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS
(Pursuant to Title 38, U.S.C., Chapter 55 and Title 12, U.S.C., Chapter 35)
NOTE: PLEASE READ THE INSTRUCTIONS ON THE REVERSE BEFORE COMPLETING THE FORM.
I. CERTIFICATE - TO BE COMPLETED BY THE FINANCIAL INSTITUTION ONLY
(SEAL OR STAMP OF FINANCIAL INSTITUTION)
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any
source other than what has been authorized by the Privacy Act of 1974 or Title 5 Code of Federal
Regulations 1.526 for routine uses (i.e. request from Congressman on behalf of a beneficiary) as
identified in the VA system of records, 37VA27, VA Supervised Fiduciary/Beneficiary Records - VA,
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The
information will be used by VA field examiners to determine whether an individual fiduciary is properly
using and maintaining an accounting of the VA beneficiary's compensation or pension payments. Failure
to furnish the requested information may result in the suspension of payments and/or appointment of a
successor fiduciary.
RESPONDENT BURDEN: We need this information to ensure proper administration of the
beneficiary's estate. Title 38, United States Code, Chapter 55 allows us to ask for this information. We
estimate that you will need an average of 3 minutes to review the instructions, find the information, and
complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB
control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at: www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
(First, middle, last)
(First, middle, last)
3. VA FILE NUMBER
1. NAME OF FIDUCIARY
2. NAME OF BENEFICIARY
C-
4A. NAME OF FINANCIAL INSTITUTION
4B. ADDRESS OF FINANCIAL INSTITUTION
(Include Area Code)
4C. NAME AND TELEPHONE NUMBER OF FINANCIAL INSTITUTION CONTACT PERSON
5. DATA IN ITEM 6 WAS ACCURATE AS OF
(Mo., day, yr.)
6. ACCOUNT INFORMATION
INTEREST EARNED/PAID SINCE
ACCOUNT NUMBER
BALANCE
TYPE OF
DEPOSITOR ACCOUNT
CURRENT
(State "None" if appropriate)
(Include interest earned)
ACCOUNT
TITLE
INTEREST RATE
AMOUNT
DATE
(A)
(C)
(G)
(B)
(D)
(E)
(F)
I CERTIFY THAT the foregoing amount(s) were on deposit to the credit of the above named fiduciary as shown by the record(s) of this financial institution.
7A. SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL
7B. TITLE OF CERTIFYING OFFICIAL
7C. DATE SIGNED
II. AUTHORIZATION - TO BE COMPLETED BY THE FIDUCIARY ONLY
I hereby authorize the financial institution named above to verify the above Certificate information to VA, and/or to provide copies of any of the
financial records described above to VA.
8. I UNDERSTAND THAT:
a. This authorization is not required as a condition of doing business with any financial institution.
b. I have the right to obtain a copy of the record kept by the financial institution when financial records are disclosed as a result of this authorization.
VA has the right to request a court order to delay my receipt of a copy of the record.
c. VA is seeking disclosure of this information under the authority of Title 38 U.S.C. 5502(b) and will use the information in conducting an audit of
estates maintained on behalf of VA beneficiaries.
d. Transfer of records to other agencies of the federal government may only be made in accordance with the provisions of
title 12 U.S.C. 3412.
e. I have the right to withhold my consent to this disclosure.
f. I have the right to seek damages, attorneys' fees, and costs for any violation of the right to financial privacy act by either VA or the financial
institution.
9A. SIGNATURE OF FIDUCIARY
9B. DATE SIGNED
VA FORM
21P-4718a
SUPERSEDES VA FORM 21-4718a, FEB 2009,
Continued on Reverse
JUL 2016
WHICH WILL NOT BE USED.
INSTRUCTIONS FOR COMPLETION OF VA FORM 21P-4718a
Section I - Certificate of Balance on Deposit
The fiduciary should complete Items 1, 2 and 3 before giving the form to the financial institution.
Only the financial institution should complete the rest of the items (4A through 7C) in this section.
The financial institution's seal or stamp must be placed in the space provided.
The financial institution should give the completed certificate to the fiduciary who will, in turn, submit it to VA with an
accounting.
Section II - Authorization to Disclose Financial Records
Only the fiduciary should complete this section.
The fiduciary may sign this section either before or after the Certificate section is completed by the financial institution.
(The fiduciary's signature in this section is not needed to allow the financial institution to complete the Certificate
section.)
An independent verification of financial records may be needed when VA audits the fiduciary's account. If so, VA will ask for
the information directly from the financial institution at a later time. At that time, VA will give the financial institution the
fiduciary's signed authorization.
VA FORM 21P-4718a, JUL 2016
ADVERTISEMENT
Page of 2