Va Form 21 4718A PDF Details

At the heart of managing Veterans Affairs (VA) benefits with utmost integrity and accountability is VA Form 21P-4718a, a document that serves as a testament to the financial stewardship of fiduciaries overseeing the assets of veterans or beneficiaries. This form, titled "Certificate of Balance on Deposit and Authorization to Disclose Financial Records," plays a pivotal role in the VA's oversight responsibilities, ensuring that the compensation or pension payments administered to beneficiaries are managed judiciously. By requiring a detailed account of the balance on deposit and granting the VA the authorization to scrutinize financial records, the form upholds the values of transparency and accountability. The form's sections are delineated for completion by the financial institution and the fiduciary respectively, emphasizing the clear roles each plays in safeguarding the interests of the VA beneficiary. The stipulations outlined – from the precise instructions for the financial institution to the rights and acknowledgments of the fiduciary – underscore the delicate balance between protecting the financial privacy of individuals and the VA's obligation to ensure the proper administration of benefits. With deadlines and respondent burdens clearly stated, along with the necessary legal authorizations rooted in U.S. Code, VA Form 21P-4718a embodies the structured process through which the VA endeavors to fulfill its commitment to veterans and their entrusted fiduciaries.

QuestionAnswer
Form NameVa Form 21 4718A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names 21P-4718a. CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS

Form Preview Example

OMB Control No. 2900-0017

Respondent Burden: 3 Minutes

Expiration Date: 12/31/2024

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.

SECTION 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. You are required to respond to obtain or retain benefits (38 U.S.C.

 

 

 

5701). 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: www.reginfo.gov/public/do/PRAMain.

 

 

 

 

 

1. NAME OF FIDUCIARY (First, middle, last)

2. NAME OF BENEFICIARY (First, middle, last)

 

 

3. VA FILE NUMBER

 

 

 

 

 

C-

4A. NAME OF FINANCIAL INSTITUTION

 

4B. ADDRESS OF FINANCIAL INSTITUTION

 

 

 

 

4C. NAME AND TELEPHONE NUMBER OF FINANCIAL INSTITUTION CONTACT PERSON (Include Area Code)

 

5. DATA IN ITEM 6 WAS ACCURATE AS OF

 

 

 

 

 

(Mo., day, yr.)

 

 

 

 

 

 

 

6. ACCOUNT INFORMATION

 

 

TYPE OF

ACCOUNT

(A)

ACCOUNT NUMBER

(State "None" if appropriate)

(B)

DEPOSITOR ACCOUNT

TITLE

(C)

BALANCE

(Include interest earned)

(D)

INTEREST EARNED/PAID SINCE

AMOUNT

DATE

(E)(F)

CURRENT

INTEREST RATE

(G)

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

(Sign in ink)

 

 

SECTION 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 (Sign in ink)

 

9B. DATE SIGNED

 

 

 

 

VA FORM

21P-4718a

SUPERSEDES VA FORM 21-4718a, DEC 2019,

PAGE 1

DEC 2021

WHICH WILL NOT BE USED.

INSTRUCTIONS FOR COMPLETION OF VA FORM 21P-4718a

Section I - Certificate of Balance on Deposit

The fiduciary should complete Items 1, 2 and 3 before giving the form to the financial institution. Only the financial institution should complete the rest of the items (4A through 7C) in this section. The financial institution's seal or stamp must be placed in the space provided.

The financial institution should give the completed certificate to the fiduciary who will, in turn, submit it to VA with an accounting.

Section II - Authorization to Disclose Financial Records

Only the fiduciary should complete this section.

The fiduciary may sign this section either before or after the Certificate section is completed by the financial institution.

(The fiduciary's signature in this section is not needed to allow the financial institution to complete the Certificate section.)

An independent verification of financial records may be needed when VA audits the fiduciary's account. If so, VA will ask for the information directly from the financial institution at a later time. At that time, VA will give the financial institution the fiduciary's signed authorization.

VA FORM 21P-4718a, DEC 2021

PAGE 2

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