Va Form 21-4718a - Veterans Benefits Administration

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OMB APPROVED NO. 2900-0017
RESPONDENT BURDEN: 3 Minutes
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
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any
(SEAL OR STAMP OF FINANCIAL INSTITUTION)
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: 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)
1. NAME OF FIDUCIARY
2. NAME OF BENEFICIARY
3. VA FILE NUMBER
C-
4A. NAME OF FINANCIAL INSTITUTION
4B. ADDRESS OF FINANCIAL INSTITUTION
(Include Area Code)
5. DATA IN ITEM 6 WAS ACCURATE AS OF
4C. NAME AND TELEPHONE NUMBER OF FINANCIAL INSTITUTION CONTACT PERSON
(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
21-4718a
Continued on Reverse
VA FORM
SUPERSEDES VA FORM 21-4718a, MAR 2006, WHICH
FEB 2009
WILL NOT BE USED.

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