21P 4706B 47063 VBA ARE
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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 NAME OF VETERAN (First-Middle-Last) NAME OF BENEFICIARY (If not veteran) VA FILE NUMBER 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 amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the entire accounting period to support the transactions noted on this accounting. IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE. ACCOUNTING PERIOD FROM TO 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 A AMOUNT RECEIVED FROM VA C AMOUNT RECEIVED FROM SOCIAL SECURITY E F G H I AMOUNT TOTAL ESTATE AT BEGINNING OF PERIOD B D NO. OF MONTHS MONTHLY AMT. NO. OF MONTHS MONTHLY AMT. NO. OF MONTHS MONTHLY AMT. NO. OF MONTHS MONTHLY AMT. $ ITEM DESCRIPTION A B TOTAL AMOUNT OF SAVINGS ACCOUNT(S) C TOTAL AMOUNT OF CERTIFICATE(S) OF DEPOSIT $ total in this field) D AMOUNT RECEIVED FROM OTHER SOURCES (1) WERE ADDITIONAL BONDS PURCHASED DURING THIS ACCOUNTING PERIOD? YES NO (2) WERE SAVINGS BONDS CASHED DURING THIS ACCOUNTING PERIOD? (List in Items 1E thru 1H) YES *TOTAL RECEIVED (ADD LINES 1A THRU 1H) AMOUNT TOTAL AMOUNT OF CHECKING ACCOUNT(S) TOTAL PURCHASE PRICE OF SAVINGS BONDS LISTED ON REVERSE (Complete reverse for INTEREST EARNED ON DEPOSITS $ 2. MONEY SPENT E NO OTHER (List outstanding checks or other issues that impact the total assets.) NO. OF MONTHS MONTHLY AMT. A ROOM AND BOARD/RENT B C CLOTHING ENTERTAINMENT D PERSONAL USE NO. OF MONTHS MONTHLY AMT. E DEPENDENT (S) SUPPORT NO. OF MONTHS MONTHLY AMT. F G H I J K L M 4. ASSETS AT END OF PERIOD* DESCRIPTION ITEM $ 5. TOTAL ASSETS (MUST EQUAL ITEM 3) $ 6. REMARKS (If needed you may attach additional sheets and key responses to item numbers.) FIDUCIARY FEE IF APPROVED BY VA OTHER (Specify) TOTAL SPENT (ADD LINES 2A THRU 2L) 3. TOTAL FUNDS UNDER MANAGEMENT AT END OF PERIOD (SUBTRACT 2M FROM 1I) $ $ * NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-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 VA FORM JUL 2016 8. SUBMITTED BY (Signature and title of fiduciary) 21P-4706b SUPERSEDES VA FORM 21-4706b, OCT 2012, WHICH WILL NOT BE USED. (Continued on Reverse) 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. 10. EXPLANATION OF BACKGROUND INFORMATION (If necessary) LINE NO. SERIAL NUMBER DATE OF PURCHASE PURCHASE PRICE LINE NO. 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. SERIAL NUMBER DATE OF PURCHASE PURCHASE PRICE 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, 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
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