VA Form 21P-4706B "VA Fiduciary's Account"

What Is VA Form 21P-4706B?

This is a legal form that was released by the U.S. Department of Veterans Affairs on December 1, 2019 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 21P-4706B by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 21P-4706B "VA Fiduciary's Account"

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OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
Expiration Date: 12/31/2021
VA FIDUCIARY'S ACCOUNT
NAME AND ADDRESS OF FIDUCIARY
VA FIDUCIARY HUB
FROM
TO
(First-Middle-Last)
(If not veteran)
VA FILE NUMBER
NAME OF VETERAN
NAME OF BENEFICIARY
C-
SECTION I - STATEMENT OF ACCOUNT
INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Hub. Show monthly
ACCOUNTING PERIOD
amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the
FROM
TO
entire accounting period to support the transactions noted on this accounting.
IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.
IMPORTANT - The fiduciary must account for all funds received on behalf of the beneficiary as VA fiduciary, representative payee for SSA benefits, or in any other
fiduciary capacity. The fiduciary must keep receipts and other documentation of expenses because VA may need to examine them during the audit of this accounting.
1. MONEY RECEIVED
4. ASSETS AT END OF PERIOD*
DESCRIPTION
AMOUNT
ITEM
DESCRIPTION
AMOUNT
ITEM
TOTAL AMOUNT OF CHECKING
A
A
TOTAL ESTATE AT BEGINNING OF PERIOD
$
ACCOUNT(S)
$
NO. OF MONTHS
MONTHLY AMT.
TOTAL AMOUNT OF SAVINGS
B
AMOUNT
ACCOUNT(S)
B
RECEIVED
NO. OF MONTHS
MONTHLY AMT.
TOTAL AMOUNT OF
FROM VA
C
CERTIFICATE(S) OF DEPOSIT
AMOUNT
NO. OF MONTHS
MONTHLY AMT.
TOTAL PURCHASE PRICE OF
SAVINGS BONDS LISTED ON
RECEIVED
(Complete reverse for
C
REVERSE
FROM
NO. OF MONTHS
MONTHLY AMT.
total in this field)
SOCIAL
SECURITY
(1) WERE ADDITIONAL BONDS
PURCHASED DURING THIS
ACCOUNTING PERIOD?
D
D
INTEREST EARNED ON DEPOSITS
YES
NO
AMOUNT RECEIVED FROM OTHER SOURCES
E
(2) WERE SAVINGS BONDS CASHED
(List in Items 1E thru 1H)
DURING THIS ACCOUNTING
PERIOD?
F
YES
NO
G
H
(List outstanding checks or other
OTHER
I
$
E
issues that impact the total assets.)
(ADD LINES 1A THRU 1H)
*TOTAL RECEIVED
2. MONEY SPENT
NO. OF MONTHS
MONTHLY AMT.
ROOM AND
A
BOARD/RENT
$
5. TOTAL ASSETS
(MUST EQUAL ITEM 3)
B
$
CLOTHING
C
ENTERTAINMENT
(If needed you may attach additional sheets and key
6. REMARKS
NO. OF MONTHS MONTHLY AMT.
PERSONAL
responses to item numbers.)
D
USE
NO. OF MONTHS
MONTHLY AMT.
DEPENDENT
E
(S) SUPPORT
F
FIDUCIARY FEE IF APPROVED BY VA
G
(Specify)
OTHER
H
I
J
K
L
M
(ADD LINES 2A THRU 2L)
$
TOTAL SPENT
3. TOTAL FUNDS UNDER MANAGEMENT AT
(SUBTRACT 2M FROM 1I)
END OF PERIOD
$
* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-4703), this is a complete accounting of all funds I received for the beneficiary.
I CERTIFY THAT this is a true account of the beneficiary's estate for the period stated, to the best of my knowledge and belief.
(Signature and title of fiduciary) (Sign in ink)
7. DATE
8. SUBMITTED BY
VA FORM
SUPERSEDES VA FORM 21-4706b, JUL 2016,
21P-4706b
(Continued on Reverse)
DEC 2019
WHICH WILL NOT BE USED.
OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
Expiration Date: 12/31/2021
VA FIDUCIARY'S ACCOUNT
NAME AND ADDRESS OF FIDUCIARY
VA FIDUCIARY HUB
FROM
TO
(First-Middle-Last)
(If not veteran)
VA FILE NUMBER
NAME OF VETERAN
NAME OF BENEFICIARY
C-
SECTION I - STATEMENT OF ACCOUNT
INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Hub. Show monthly
ACCOUNTING PERIOD
amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the
FROM
TO
entire accounting period to support the transactions noted on this accounting.
IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.
IMPORTANT - The fiduciary must account for all funds received on behalf of the beneficiary as VA fiduciary, representative payee for SSA benefits, or in any other
fiduciary capacity. The fiduciary must keep receipts and other documentation of expenses because VA may need to examine them during the audit of this accounting.
1. MONEY RECEIVED
4. ASSETS AT END OF PERIOD*
DESCRIPTION
AMOUNT
ITEM
DESCRIPTION
AMOUNT
ITEM
TOTAL AMOUNT OF CHECKING
A
A
TOTAL ESTATE AT BEGINNING OF PERIOD
$
ACCOUNT(S)
$
NO. OF MONTHS
MONTHLY AMT.
TOTAL AMOUNT OF SAVINGS
B
AMOUNT
ACCOUNT(S)
B
RECEIVED
NO. OF MONTHS
MONTHLY AMT.
TOTAL AMOUNT OF
FROM VA
C
CERTIFICATE(S) OF DEPOSIT
AMOUNT
NO. OF MONTHS
MONTHLY AMT.
TOTAL PURCHASE PRICE OF
SAVINGS BONDS LISTED ON
RECEIVED
(Complete reverse for
C
REVERSE
FROM
NO. OF MONTHS
MONTHLY AMT.
total in this field)
SOCIAL
SECURITY
(1) WERE ADDITIONAL BONDS
PURCHASED DURING THIS
ACCOUNTING PERIOD?
D
D
INTEREST EARNED ON DEPOSITS
YES
NO
AMOUNT RECEIVED FROM OTHER SOURCES
E
(2) WERE SAVINGS BONDS CASHED
(List in Items 1E thru 1H)
DURING THIS ACCOUNTING
PERIOD?
F
YES
NO
G
H
(List outstanding checks or other
OTHER
I
$
E
issues that impact the total assets.)
(ADD LINES 1A THRU 1H)
*TOTAL RECEIVED
2. MONEY SPENT
NO. OF MONTHS
MONTHLY AMT.
ROOM AND
A
BOARD/RENT
$
5. TOTAL ASSETS
(MUST EQUAL ITEM 3)
B
$
CLOTHING
C
ENTERTAINMENT
(If needed you may attach additional sheets and key
6. REMARKS
NO. OF MONTHS MONTHLY AMT.
PERSONAL
responses to item numbers.)
D
USE
NO. OF MONTHS
MONTHLY AMT.
DEPENDENT
E
(S) SUPPORT
F
FIDUCIARY FEE IF APPROVED BY VA
G
(Specify)
OTHER
H
I
J
K
L
M
(ADD LINES 2A THRU 2L)
$
TOTAL SPENT
3. TOTAL FUNDS UNDER MANAGEMENT AT
(SUBTRACT 2M FROM 1I)
END OF PERIOD
$
* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-4703), this is a complete accounting of all funds I received for the beneficiary.
I CERTIFY THAT this is a true account of the beneficiary's estate for the period stated, to the best of my knowledge and belief.
(Signature and title of fiduciary) (Sign in ink)
7. DATE
8. SUBMITTED BY
VA FORM
SUPERSEDES VA FORM 21-4706b, JUL 2016,
21P-4706b
(Continued on Reverse)
DEC 2019
WHICH WILL NOT BE USED.
9. BACKGROUND INFORMATION
Answer the questions below if you are an individual appointed to serve as fiduciary for the beneficiary named on the reverse side of this form.
The questions pertain to your personal criminal and credit history. Failure to provide a response may impact your ability to serve as a VA fiduciary.
You are not required to respond to these questions if you are serving as VA fiduciary in one of the following capacities for the beneficiary named on the
reverse:
• administrator of a facility
• company or corporation
• court-appointed fiduciary who is also appointed by VA
I certify that during this accounting period, I have not been convicted of any offense under Federal or State law, which resulted in imprisonment for more
than one year. I understand the Department of Veterans Affairs may obtain my criminal background history to verify my response. Initial the box below
to certify and acknowledge this information.
I certify that during this accounting period, I did not default on a debt, was not the subject of collection action by a creditor and did not file bankruptcy.
To the best of my knowledge, no adverse credit information was reported to a credit bureau because I was unable to meet my personal financial
obligations. I understand the Department of Veterans Affairs may obtain my credit history report to verify my response. Initial the box below to certify
and acknowledge this information.
(If necessary)
10. EXPLANATION OF BACKGROUND INFORMATION
LINE
DATE OF
PURCHASE
LINE
DATE OF
PURCHASE
SERIAL NUMBER
SERIAL NUMBER
NO.
PURCHASE
PRICE
NO.
PURCHASE
PRICE
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
SECTION II - CERTIFICATION OF U.S. SAVINGS BONDS
I CERTIFY THAT the savings bonds listed above are the property of the estate of the beneficiary and are in my custody and control.
SIGNATURE OF FIDUCIARY (Sign in ink)
DATE
PRIVACY ACT INFORMATION: The VA will not disclose information on the form to any source other than what has been authorized under 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 and General Investigative Records, published in the Federal Register. You are required to respond (38 U.S.C.
5701) to obtain or retain benefits. The information will be used to ensure the proper administration of the beneficiary's income and estate. Failure to furnish the
requested information may result in the suspension of payments and/or the 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 allows us to ask for this
information. We estimate that you will need an average of 27 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 https://reginfo.gov/public/do/PRAMain.
VA FORM 21P-4706b, DEC 2019
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