VA Form 21P-4706C Court Appointed Fiduciary's Account

VA Form 21P-4706C is a U.S. Department of Veterans Affairs form also known as the "Court Appointed Fiduciary's Account". The latest edition of the form was released in July 1, 2016 and is available for digital filing.

Download an up-to-date VA Form 21P-4706C in PDF-format down below or look it up on the U.S. Department of Veterans Affairs Forms website.

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OMB Control No. 2900-0017
Respondent Burden: 30 Minutes
Expiration Date: 07/31/2019
COURT APPOINTED FIDUCIARY'S ACCOUNT
(First-Middle-Last)
NAME OF VETERAN
VA FILE NUMBER
C-
IN THE
COURT OF
}
IN THE MATTER OF THE ESTATE OF
STATEMENT OF ACCOUNT
to
(Minor or Incompetent)
(Date)
(Date)
SECTION I - RECEIPTS
RECEIVED FROM
DATE
AMOUNT
(Report income from or liquidation of each investment separately)
$
TOTAL RECEIPTS
$
VA FORM
EXISTING STOCKS OF VA FORM 27-4706c,
21P-4706c
JUL 2016
OCT 2012, WILL NOT BE USED.
OMB Control No. 2900-0017
Respondent Burden: 30 Minutes
Expiration Date: 07/31/2019
COURT APPOINTED FIDUCIARY'S ACCOUNT
(First-Middle-Last)
NAME OF VETERAN
VA FILE NUMBER
C-
IN THE
COURT OF
}
IN THE MATTER OF THE ESTATE OF
STATEMENT OF ACCOUNT
to
(Minor or Incompetent)
(Date)
(Date)
SECTION I - RECEIPTS
RECEIVED FROM
DATE
AMOUNT
(Report income from or liquidation of each investment separately)
$
TOTAL RECEIPTS
$
VA FORM
EXISTING STOCKS OF VA FORM 27-4706c,
21P-4706c
JUL 2016
OCT 2012, WILL NOT BE USED.
SECTION II - EXPENDITURES
TO WHOM PAID AND PURPOSE
AMOUNT
DATE
$
TOTAL EXPENDITURES
$
VA FORM 21P-4706c, JUL 2016
SECTION III - SUMMARY OF ACCOUNT
CASH BALANCE FROM LAST ACCOUNTING
$
TOTAL RECEIPTS
$
TOTAL
$
TOTAL EXPENDITURES
$
CASH BALANCE IN ESTATE
$
INVESTMENTS (Cost value)
BALANCE ON HAND LAST ACCOUNT
$
ACQUIRED DURING PERIOD
$
TOTAL
$
LIQUIDATED DURING PERIOD
$
TOTAL ON HAND
$
TOTAL VALUE OF ESTATE
$
}
STATE OF
COUNTY OF
SS
I
being duly Sworn, depose and say
of the estate of
who is now residing at
that this is a full and true account of the beneficiary's estate for the period stated, to the best of my knowledge and belief.
(Signature of Fiduciary)
Subscribed and Sworn to before me this
day of
,
A.D.
(Signature and Title)
SECTION IV - CERTIFICATE OF BALANCE ON DEPOSIT
NAME AND ADDRESS OF INSTITUTION
I CERTIFY THAT on the
day of
,
, there was on deposit in this Institution
to the credit of this Fiduciary the following:
Checking Account Balance $
Account Number
Savings Account Balance $
Account Number
Including interest of $
paid during period of Statement of Account at
% .
SEAL OR STAMP OF FINANCIAL INSTITUTION
(Signature and Title of Certifying Official)
VA FORM 21P-4706c, JUL 2016
SECTION V - CERTIFICATE AS TO SECURITIES
INTEREST
DATE OF
FACE
KIND OF BOND OR SECURITY
COST
RATE
PURCHASE
VALUE
$
$
I CERTIFY THAT the securities listed above were exhibited to me by the Fiduciary and are the property of the beneficiary and are in the custody and
control of the Fiduciary.
SIGNATURE AND TITLE OF CERTIFYING OFFICIAL
DATE
ADDRESS OF CERTIFYING OFFICIAL
NOTE: This Certificate may be executed by the Judge or Clerk of Court of your appointment, an official of the safety deposit company or bank
wherein you have securities in lock box, or by any authorized official or agent of the company which is surety on your bond.
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 1.576 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 30 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. Valid OMB control numbers can be located on the OMB Internet Page
at: http://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.
VA FORM 21P-4706c, JUL 2016

Download VA Form 21P-4706C Court Appointed Fiduciary's Account

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