Fillable Va Form 29-389 - Notice Of Lapse (Page 2 of 2) in pdf

OMB Control No. 2900-0128

Respondent Burden: 12 minutes

APPLICATION FOR REINSTATEMENT

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title

38, Code of Federal Regulations 1.576 for routine uses (i.e., to reinstate lapsed government life insurance) as identified in the VA system of records, 36VA00, Veterans

and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the Federal Register. Your obligation to respond is required to obtain or

retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an

individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and

still in effect. The responses you submit are considered confidential (38 U.S.C. 5701).

Respondent Burden: We need this information to determine your eligibility for reinstatement (38 U.S.C. 722). Title 38, United States Code, allows us to ask for this

information. We estimate that you will need an average of 12 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.

BE SURE TO INSERT ALL INFORMATION - DATE - SIGN AND MAIL IMMEDIATELY WITH THE TOTAL AMOUNT.

1. AMOUNT OF INSURANCE TO

2. AMOUNT OF TOTAL DISABILITY INCOME

3. AMOUNT SENT WITH

4. SOCIAL SECURITY

BE REINSTATED

PROVISION TO BE REINSTATED

THIS APPLICATION

NUMBER

CERTIFICATION OF HEALTH

5A. I am applying for reinstatement of my insurance in the amount shown above. As a condition to the reinstatement of this insurance,

I certify that to the best of my knowledge and belief, I am in as good health now as I was on the last day of the grace period (31 days

after the date of lapse).

YES

(If "No," please complete Item 5B)

5B. Please describe any illness, disease, injury or medical treatment with dates, which have occurred since the date of lapse.

I UNDERSTAND THAT:

A. If my application is approved, the last named beneficiary(ies) and selection of optional settlement(s) on policy(ies) reinstated, will

continue in effect unless the Department of Veterans Affairs receives a request for a change in writing over my signature. (VA Form

29-336 should be used to make any changes.)

B. STATEMENTS MADE BY ME IN THIS APPLICATION ARE RELIED UPON. ANY DECEPTION OR FALSE STATEMENT

EITHER BY INFERENCE, OMISSION, OR OTHERWISE, MAY CAUSE CANCELLATION OF THE INSURANCE OR

REFUSAL TO PAY A CLAIM. IN EITHER CASE, PREMIUMS MAY NOT BE RETURNED.

C. I must let the Department of Veterans Affairs know of any change in my health beginning after the date I sign and before the date I

send this form to the Department of Veterans Affairs.

IMPORTANT: This form must be fully COMPLETED, SIGNED and sent IMMEDIATELY to the Department of Veterans Affairs.

Checks and money orders should be made payable to the Department of Veterans Affairs.

Department of Veterans Affairs

Regional Office and Insurance Center

P.O. Box 7208

Philadelphia, PA 19101

6. MAILING ADDRESS (Please complete only if your address shown on the front is not correct)

7. TELEPHONE NUMBER

8. SIGNATURE OF POLICYHOLDER (Do not print. This certification must be signed and dated)

9. DATE OF SIGNATURE

PENALTY - The law provides whoever makes any statement of material fact knowing it to be false shall be punished by fine or imprisonment or both.

VA FORM 29-389, NOV 2005

Va Form 29-389 - Notice Of Lapse Page 2

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