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

What IS VA Form 21P-4706b?

VA Form 21P-4706B, Federal Fiduciary's Account is a document used to report the complete accounting of the beneficiary's estate for the period stated by the Department of Veterans Affairs (VA). An accounting should contain opening account balance, funds the individual (fiduciary) handles for the beneficiary, full list of expenses paid from these funds, and closing account balance. All this data is required to ensure the beneficiary's account is managed properly.

The latest version of the form was released by the VA in July 2016 and supersedes the now obsolete VA Form 21-4706B. An up-to-date fillable version of the form is available for digital filing and download below or can be found on the VA website.

The VA Form 21P-4706B has several related forms:

ADVERTISEMENT

VA Form 21P-4706B Instructions

The instructions for completion of the VA Form 21P-4706B are provided in Section I of the document. You are obliged to account for all funds obtained on the beneficiary's behalf, including VA funds, military retirement pay, and Social Security Administration (SSA) funds. All the receipts and other documentation of expenses must be kept, since they may be requested during the audit of the submitted account. You should not indicate in the report any funds you do not manage on the behalf of the beneficiary.

If the personal assistance is needed, you may call toll-free at 1-888-407-0144 or contact the fiduciary hub of jurisdiction for help.

How to Fill out VA Form 21P-4706b?

The VA Form 21P-4706B should be completed as follows:

  • "From". Enter your name and full address;
  • "To". Enter the address of the fiduciary hub. It can be found in the letter informing about the accounting;
  • "Name of Veteran". Enter the full name of the veteran;
  • "Name of Beneficiary". If the beneficiary (person entitled to receive funds) is someone other than the veteran, provide their name;
  • "File Number". Enter the claim number or SSN. It can be found in the top right corner of the letters received from the VA;
  • Enter the dates of the accounting period in the notification letter;
  • "Money Received" includes Items A to I. If it's the first accounting, the Item 1A should contain "$0". Otherwise, the ending balance from the previous accounting must be indicated;
  • The number of months and the monthly amount of funds you managed during the accounting period on the behalf of the beneficiary must be provided in the corresponding boxes of the Item 1B. Besides, this part should include any retroactive funds received during this period. If the amount varied more than twice, it is allowed to use Items 1E through 1H to provide full information;
  • If the SSA recognizes you as the representative payee on the beneficiary's behalf, the corresponding amount of the SSA funds is required to be entered in the Item 1C;
  • Item 1D is for the amount of interest received for funds deposited in a bank;
  • All funds received from other sources must be indicated in the Items 1E to 1H;
  • Total amount received is provided in the Item 1I;
  • "Money Spent". Indicate the amounts paid for room and board, clothing, entertainment of the beneficiary, for support of beneficiary's dependents, and other expenses. The total amount of the funds spent must be entered in the Item 2M;
  • Subtract 2M from 1I and enter the amount in the Box 3 "Total Estate at End of Period";
  • Section IV. Enter the assets at the end of the accounting period;
  • Box 5. The total amount of assets. The sum provided in box 5 should concur with the sum indicated in box 3;
  • Box 6 is for any additional information and remarks.

Sign the document after completion. The reverse part of the form is optional and should be filled out only if you are appointed to serve as a fiduciary for the beneficiary named in the account.

How Can I Submit VA Form 21P-4706B?

VA Form 21P-4706B can be submitted in person or via mail to the Fiduciary Hub. The address of the Fiduciary Hub is the address indicated in the Box "To" on the top of the document.

ADVERTISEMENT

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

1511 times
Rate (4.3 / 5) 72 votes
OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
Expiration Date: 07/31/2019
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*
ITEM
DESCRIPTION
AMOUNT
ITEM
DESCRIPTION
AMOUNT
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
issues that impact the total assets.)
I
(ADD LINES 1A THRU 1H)
$
E
*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
(ADD LINES 2A THRU 2L)
M
$
TOTAL SPENT
3. TOTAL FUNDS UNDER MANAGEMENT AT
(SUBTRACT 2M FROM 1I)
END OF PERIOD
$
* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21-4703), 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)
7. DATE
8. SUBMITTED BY
VA FORM
21P-4706b
EXISTING STOCKS OF VA FORM 21-4706b, OCT 2012,
(Continued on Reverse)
JUL 2016
WILL NOT BE USED.
OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
Expiration Date: 07/31/2019
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*
ITEM
DESCRIPTION
AMOUNT
ITEM
DESCRIPTION
AMOUNT
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
issues that impact the total assets.)
I
(ADD LINES 1A THRU 1H)
$
E
*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
(ADD LINES 2A THRU 2L)
M
$
TOTAL SPENT
3. TOTAL FUNDS UNDER MANAGEMENT AT
(SUBTRACT 2M FROM 1I)
END OF PERIOD
$
* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21-4703), 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)
7. DATE
8. SUBMITTED BY
VA FORM
21P-4706b
EXISTING STOCKS OF VA FORM 21-4706b, OCT 2012,
(Continued on Reverse)
JUL 2016
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
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, and published in the Federal Register. Your obligation to respond is
required 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 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-4706b, JUL 2016

Video Instructions for VA Form 21P-4706B

Page of 2