Currently, the Department of Veterans Affairs (VA) is facing scrutiny for its treatment of veterans. This has led to some changes in how the VA provides services to veterans. One such change is the use of va form 21p 4706b. The purpose of this form is to provide a clear and concise summary of a veteran's medical history. By doing so, VA can better ensure that veterans receive appropriate care. In order to complete va form 21p 4706b, you will need access to your medical records from all providers. You should also include information about any military service-related injuries or illnesses. Completing va form 21p 4706b can be a daunting task, but it's important that you provide as much information as possible.
Listed here, you can see quite a few particulars about va form 21p 4706b PDF. It's worth making the effort to learn this just before you start submitting your form.
| Question | Answer |
|---|---|
| Form Name | Va Form 21P 4706B |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names |
OMB Control No.
Respondent Burden: 27 Minutes
Expiration Date: 12/31/2021
VA FIDUCIARY'S ACCOUNT
NAME AND ADDRESS OF FIDUCIARY
FROM
NAME OF VETERAN
VA FIDUCIARY HUB
TO
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
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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.
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1. MONEY RECEIVED |
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4. ASSETS AT END OF PERIOD* |
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ITEM |
DESCRIPTION |
AMOUNT |
ITEM |
DESCRIPTION |
AMOUNT |
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A |
TOTAL ESTATE AT BEGINNING OF PERIOD |
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A |
TOTAL AMOUNT OF CHECKING |
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ACCOUNT(S) |
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NO. OF MONTHS MONTHLY AMT. |
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B |
TOTAL AMOUNT OF SAVINGS |
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AMOUNT |
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ACCOUNT(S) |
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BRECEIVED
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FROM VA |
NO. OF MONTHS |
MONTHLY AMT. |
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C |
TOTAL AMOUNT OF |
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CERTIFICATE(S) OF DEPOSIT |
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AMOUNT |
NO. OF MONTHS |
MONTHLY AMT. |
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TOTAL PURCHASE PRICE OF |
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RECEIVED |
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SAVINGS BONDS LISTED ON |
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C |
FROM |
NO. OF MONTHS |
MONTHLY AMT. |
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REVERSE (Complete reverse for |
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SOCIAL |
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total in this field) |
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SECURITY |
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(1) WERE ADDITIONAL BONDS |
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PURCHASED DURING THIS |
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D |
INTEREST EARNED ON DEPOSITS |
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D |
ACCOUNTING PERIOD? |
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YES |
NO |
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E |
AMOUNT RECEIVED FROM OTHER SOURCES |
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(2) WERE SAVINGS BONDS CASHED |
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(List in Items 1E thru 1H) |
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DURING THIS ACCOUNTING |
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F |
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PERIOD? |
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YES |
NO |
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G |
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H |
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OTHER (List outstanding checks or other |
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I |
*TOTAL RECEIVED (ADD LINES 1A THRU 1H) |
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$ |
E |
issues that impact the total assets.) |
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2. MONEY SPENT |
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A |
ROOM AND |
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NO. OF MONTHS |
MONTHLY AMT. |
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BOARD/RENT |
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$ |
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5. TOTAL ASSETS |
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B |
CLOTHING |
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(MUST EQUAL ITEM 3) |
$ |
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C |
ENTERTAINMENT |
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6. REMARKS (If needed you may attach additional sheets and key |
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D |
PERSONAL |
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NO. OF MONTHS |
MONTHLY AMT. |
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responses to item numbers.) |
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USE |
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E |
DEPENDENT |
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NO. OF MONTHS |
MONTHLY AMT. |
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(S) SUPPORT |
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F |
FIDUCIARY FEE IF APPROVED BY VA |
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G |
OTHER (Specify) |
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H |
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I |
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J |
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K |
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L |
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M |
TOTAL SPENT (ADD LINES 2A THRU 2L) |
$ |
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3. TOTAL FUNDS UNDER MANAGEMENT AT |
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END OF PERIOD (SUBTRACT 2M FROM 1I) |
$ |
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*NOTE: Pursuant to my signed Fiduciary Agreement (VA Form
7. DATE
8.SUBMITTED BY (Signature and title of fiduciary) (Sign in ink)
VA FORM |
SUPERSEDES VA FORM |
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DEC 2019 |
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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
•
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.
SERIAL NUMBER
DATE OF
PURCHASE
PURCHASE
PRICE
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
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 (Sign in ink)
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. You are required to respond (38 U.S.C. 5701) 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 https://reginfo.gov/public/do/PRAMain.
VA FORM