Va Form 21p-4706b - Federal Fiduciary'S Account
ADVERTISEMENT
1
2OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
FEDERAL FIDUCIARY'S ACCOUNT
VA FIDUCIARY ACTIVITY
NAME AND ADDRESS OF FIDUCIARY
Penelope Garcia
FROM
TO
432 Anderson St.
Mt. Rocky, TN, 55555
NAME OF VETERAN (First-Middle-Last)
VA FILE NUMBER
NAME OF BENEFICIARY (
If not veteran)
Derrick Paul Morgan
TRA-11-1234
C-
SECTION I - STATEMENT OF ACCOUNT
INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Activity. Show monthly
ACCOUNTING PERIOD
amount where indicated, in addition to amount for accounting period. Attach a completed Certification of Funds on Deposit, (VA
FROM
TO
Form 21-4718a) if this accounting shows any funds on deposit.
July 15, 2013
July 15, 2014
IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.
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*
DESCRIPTION
AMOUNT
ITEM
DESCRIPTION
AMOUNT
ITEM
CASH ON HAND (NOT ON DEPOSIT
.00
A
$
A
$
TOTAL ESTATE AT BEGINNING OF PERIOD
IN BANK)
NO. OF MONTHS
MONTHLY AMT.
33,228.00
B
AMOUNT IN CHECKING ACCOUNT
AMOUNT
12
2,769.00
B
RECEIVED
NO. OF MONTHS
MONTHLY AMT.
FROM VA
C
AMOUNT IN SAVINGS ACCOUNT
NO. OF MONTHS
MONTHLY AMT.
TOTAL PURCHASE PRICE OF
AMOUNT
RECEIVED
SAVINGS BONDS LISTED ON
C
FROM
REVERSE (Complete reverse for total in
NO. OF MONTHS
MONTHLY AMT.
SOCIAL
this field)
SECURITY
(1) IF PURCHASE PRICE OF SAVINGS
BONDS CHANGED FROM THE LAST
ACCOUNTING PERIOD, WERE
49.00
D
INTEREST EARNED ON DEPOSITS
ADDITIONAL BONDS PURCHASED?
D
NO
AMOUNT RECEIVED FROM OTHER SOURCES
YES
E
(List in Items 1E thru 1H)
(2) WERE SAVINGS BONDS CASHED
VA Funds from Derrick
3,000.00
DURING THE ACCOUNTING PERIOD?
F
VA Retroactive Payment
13,000.00
G
YES
NO
H
49,277.00
I
*TOTAL RECEIVED (ADD LINES 1A THRU 1H)
$
OTHER (Specify)
2. MONEY SPENT
E
NO. OF MONTHS
MONTHLY AMT.
ROOM AND
A
$
BOARD/RENT
5. TOTAL ASSETS
$
(MUST EQUAL ITEM 3)
B
CLOTHING
C
6. REMARKS (If needed you may continue in
ENTERTAINMENT
NO. OF MONTHS MONTHLY AMT.
"Remarks" section on reverse or, if necessary, attach
PERSONAL
D
USE
additional sheets and key responses to item numbers.)
NO. OF MONTHS
MONTHLY AMT.
DEPENDENT(S)
E
SUPPORT
F
FIDUCIARY FEE IF APPROVED BY VA
OTHER (Specify)
G
H
I
J
K
L
TOTAL SPENT (ADD LINES 2A THRU 2L)
M
$
3. TOTAL ESTATE AT END OF PERIOD
$
(SUBTRACT 2M FROM 1I)
* 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.
7. DATE
8. SUBMITTED BY (Signature and title of fiduciary)
9. DATE APPROVED
10. APPROVED BY (Signature and title of VA official)
(Continued on Reverse)
VA FORM
EXISTING STOCKS OF VA FORM 21-4706b, MAR 2006,
21P-4706b
WILL NOT BE USED.
OCT 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21p-534ez - Notice To Survivor Of Evidence Necessary To Substantiate A Claim For Dependency And Indemnity Compensation, Death Pension, And/or Accrued Benefits
Legal
Related Categories
Parent category: Legal