Get Va Fiduciary Application Form 2019-2024

DATE 8. SUBMITTED BY Signature and title of fiduciary 9. DATE APPROVED VA FORM OCT 2012 21P-4706b 10. APPROVED BY Signature and title of VA official EXISTING STOCKS OF VA FORM 21-4706b MAR 2006 WILL NOT BE USED. NOTE Pursuant to my signed Fiduciary Agreement VA Form 21-4703 this is a complete accounting of all funds I received for the beneficiary. Show monthly amount where indicated in addition to amount for accounting period. Attach a completed Certification of Funds on Deposit VA Form 21-4718a if this accounting shows any funds on deposit. IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE. ACCOUNTING PERIOD IMPORTANT - The fiduciary should 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 A TOTAL ESTATE AT BEGINNING OF PERIOD B AMOUNT RECEIVED FROM VA NO. Continued on Reverse 6. REMARKS Continued LINE NO. SERIAL NUMBER SECTION II - CERTIFICATION OF U.S. SAVINGS BONDS DATE OF PURCHASE LINE SERIAL NUMBER PURCHASE PRICE 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. OF MONTHS C SOCIAL SECURITY MONTHLY AMT. AMOUNT IN CHECKING ACCOUNT AMOUNT IN SAVINGS ACCOUNT DESCRIPTION CASH ON HAND NOT ON DEPOSIT IN BANK ITEM D AMOUNT RECEIVED FROM OTHER SOURCES List in Items 1E thru 1H F G H I 1 IF PURCHASE PRICE OF SAVINGS BONDS CHANGED FROM THE LAST ADDITIONAL BONDS PURCHASED YES 2. MONEY SPENT ROOM AND BOARD/RENT CLOTHING ENTERTAINMENT PERSONAL USE E DEPENDENT S SUPPORT J K L M NO 2 WERE SAVINGS BONDS CASHED DURING THE ACCOUNTING PERIOD TOTAL RECEIVED ADD LINES 1A THRU 1H TOTAL PURCHASE PRICE OF SAVINGS BONDS LISTED ON REVERSE Complete reverse for total in this field INTEREST EARNED ON DEPOSITS OTHER Specify FIDUCIARY FEE IF APPROVED BY VA TOTAL SPENT ADD LINES 2A THRU 2L SUBTRACT 2M FROM 1I 5. TOTAL ASSETS MUST EQUAL ITEM 3 6. REMARKS If needed you may continue in Remarks section on reverse or if necessary attach additional sheets and key responses to item numbers. 1. MONEY RECEIVED 4. ASSETS AT END OF PERIOD A TOTAL ESTATE AT BEGINNING OF PERIOD B AMOUNT RECEIVED FROM VA NO. OF MONTHS C SOCIAL SECURITY MONTHLY AMT. AMOUNT IN CHECKING ACCOUNT AMOUNT IN SAVINGS ACCOUNT DESCRIPTION CASH ON HAND NOT ON DEPOSIT IN BANK ITEM D AMOUNT RECEIVED FROM OTHER SOURCES List in Items 1E thru 1H F G H I 1 IF PURCHASE PRICE OF SAVINGS BONDS CHANGED FROM THE LAST ADDITIONAL BONDS PURCHASED YES 2. MONEY SPENT ROOM AND BOARD/RENT CLOTHING ENTERTAINMENT PERSONAL USE E DEPENDENT S SUPPORT J K L M NO 2 WERE SAVINGS BONDS CASHED DURING THE ACCOUNTING PERIOD TOTAL RECEIVED ADD LINES 1A THRU 1H TOTAL PURCHASE PRICE OF SAVINGS BONDS LISTED ON REVERSE Complete reverse for total in this field INTEREST EARNED ON DEPOSITS OTHER Specify FIDUCIARY FEE IF APPROVED BY VA TOTAL SPENT ADD LINES 2A THRU 2L SUBTRACT 2M FROM 1I 5. IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE. ACCOUNTING PERIOD IMPORTANT - The fiduciary should 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 A TOTAL ESTATE AT BEGINNING OF PERIOD B AMOUNT RECEIVED FROM VA NO. OF MONTHS C SOCIAL SECURITY MONTHLY AMT. AMOUNT IN CHECKING ACCOUNT AMOUNT IN SAVINGS ACCOUNT DESCRIPTION CASH ON HAND NOT ON DEPOSIT IN BANK ITEM D AMOUNT RECEIVED FROM OTHER SOURCES List in Items 1E thru 1H F G H I 1 IF PURCHASE PRICE OF SAVINGS BONDS CHANGED FROM THE LAST ADDITIONAL BONDS PURCHASED YES 2.