Va Form 21 4718A is a document used by the United States Department of Veterans Affairs to determine the eligibility of a veteran for certain benefits. The form is used to evaluate a veteran's income and assets, as well as their household composition. The information on Va Form 21 4718A can be used to determine whether a veteran is eligible for various benefits, including but not limited to: disability compensation, pension, education assistance, and home loans. Va Form 21 4718A should be filled out by the veteran or their representative and returned to the VA for processing.
This page provides information about va form 21 4718a. There, you will find the specifics of the PDF you would like to fill out, along with the likely time to complete it along with other details.
|Form Name||Va Form 21 4718A|
|Form Length||2 pages|
|Avg. time to fill out||30 sec|
OMB Control No.
Respondent Burden: 3 Minutes
Expiration Date: 12/31/2021
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 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.
(SEAL OR STAMP OF FINANCIAL INSTITUTION)
1.NAME OF FIDUCIARY (First, middle, last)
2.NAME OF BENEFICIARY (First, middle, last)
3. VA FILE NUMBER
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
(State "None" if appropriate)
(Include interest earned)
INTEREST EARNED/PAID SINCE
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
(Sign in ink)
7B. TITLE OF CERTIFYING OFFICIAL
7C. DATE SIGNED
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
SUPERSEDES VA FORM
CONTINUED ON REVERSE
WHICH WILL NOT BE USED.
INSTRUCTIONS FOR COMPLETION OF VA FORM
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.