Va Form 21P 4706B PDF Details

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.

QuestionAnswer
Form NameVa Form 21P 4706B
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

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OMB Control No. 2900-0017

Respondent Burden: 27 Minutes

Expiration Date: 12/31/2021

VA FIDUCIARY'S ACCOUNT

NAME AND ADDRESS OF FIDUCIARY

FROM

NAME OF VETERAN (First-Middle-Last)

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

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

 

 

 

4. ASSETS AT END OF PERIOD*

 

ITEM

DESCRIPTION

AMOUNT

ITEM

DESCRIPTION

AMOUNT

 

 

 

 

 

 

 

A

TOTAL ESTATE AT BEGINNING OF PERIOD

 

A

TOTAL AMOUNT OF CHECKING

 

 

ACCOUNT(S)

$

 

$

 

 

 

NO. OF MONTHS MONTHLY AMT.

 

B

TOTAL AMOUNT OF SAVINGS

 

 

AMOUNT

 

ACCOUNT(S)

 

 

 

 

 

 

 

 

 

 

 

BRECEIVED

 

FROM VA

NO. OF MONTHS

MONTHLY AMT.

 

C

TOTAL AMOUNT OF

 

 

 

 

 

 

 

CERTIFICATE(S) OF DEPOSIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT

NO. OF MONTHS

MONTHLY AMT.

 

 

TOTAL PURCHASE PRICE OF

 

 

RECEIVED

 

 

 

 

 

 

SAVINGS BONDS LISTED ON

 

C

FROM

NO. OF MONTHS

MONTHLY AMT.

 

 

REVERSE (Complete reverse for

 

 

SOCIAL

 

 

total in this field)

 

 

 

 

 

 

 

 

 

 

SECURITY

 

 

 

 

 

 

(1) WERE ADDITIONAL BONDS

 

 

 

 

 

 

 

 

 

PURCHASED DURING THIS

 

D

INTEREST EARNED ON DEPOSITS

 

D

ACCOUNTING PERIOD?

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

E

AMOUNT RECEIVED FROM OTHER SOURCES

 

 

 

 

 

 

 

(2) WERE SAVINGS BONDS CASHED

 

(List in Items 1E thru 1H)

 

 

 

 

 

 

 

 

 

 

DURING THIS ACCOUNTING

 

F

 

 

 

 

 

 

 

PERIOD?

 

 

 

 

 

 

 

 

 

YES

NO

 

G

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

OTHER (List outstanding checks or other

 

I

*TOTAL RECEIVED (ADD LINES 1A THRU 1H)

 

$

E

issues that impact the total assets.)

 

 

2. MONEY SPENT

 

 

 

 

 

A

ROOM AND

 

NO. OF MONTHS

MONTHLY AMT.

 

 

 

 

 

 

BOARD/RENT

 

 

 

 

$

 

5. TOTAL ASSETS

 

 

 

 

 

 

 

 

B

CLOTHING

 

 

 

 

 

 

(MUST EQUAL ITEM 3)

$

C

ENTERTAINMENT

 

 

 

6. REMARKS (If needed you may attach additional sheets and key

D

PERSONAL

 

NO. OF MONTHS

MONTHLY AMT.

 

responses to item numbers.)

 

 

 

 

 

 

 

USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

DEPENDENT

 

NO. OF MONTHS

MONTHLY AMT.

 

 

 

 

 

(S) SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

FIDUCIARY FEE IF APPROVED BY VA

 

 

 

 

 

G

OTHER (Specify)

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

J

 

 

 

 

 

 

 

 

 

 

K

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

M

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

8.SUBMITTED BY (Signature and title of fiduciary) (Sign in ink)

VA FORM

21P-4706B

SUPERSEDES VA FORM 21-4706b, JUL 2016,

DEC 2019

 

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.

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 21P-4706b, DEC 2019

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