Va Form 29 4125 PDF Details

The VA 29 4125 form, known as the Claim for One Sum Payment Government Life Insurance, is an important document for beneficiaries of veterans' life insurance policies. This form must be completed to initiate the process for a one-time payment following the death of an insured veteran. The form requires various pieces of information, including the insurance file and policy numbers, detailed personal information about the insured veteran and the beneficiary, and a photocopy of the veteran's death certificate or a statement from the attending physician that shows the date and cause of death. Additionally, it's necessary for the beneficiary, guardian, or fiduciary to sign this form to enable the payment process. The document also discusses the option for beneficiaries to receive payments electronically, necessitating details about the bank account where the sum should be transferred. Furthermore, the form includes a section on the privacy act notice, emphasizing the confidentiality with which the Department of Veterans Affairs will treat the provided information. As part of the commitment to transparency and efficiency, the VA outlines the necessity of this information for the verification of eligibility for benefits, underlining the significance of accurate and complete submissions for the expedient processing of claims. With an OMB-approved number and an estimated respondent burden of 6 minutes, this document is designed to be user-friendly while adhering to federal regulations, thus facilitating a smoother transition for beneficiaries during challenging times.

QuestionAnswer
Form NameVa Form 29 4125
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdepartment of veterans affairs form 29 4125, va insurance form submission, va 29 4125, why education is important essay

Form Preview Example

OMB Approved No. 2900-0060

Respondent Burden: 6 Minutes

Expiration Date: 10/31/2022

CLAIM FOR ONE SUM PAYMENT

GOVERNMENT LIFE INSURANCE

1. INSURANCE FILE NUMBER

2. INSURANCE POLICY NUMBER

3. FIRST, MIDDLE, LAST NAME OF INSURED VETERAN

4. DATE OF DEATH

INSTRUCTIONS

WE NEED A PHOTOCOPY OF THE VETERAN'S DEATH CERTIFICATE OR A STATEMENT FROM THE ATTENDING PHYSICIAN SHOWING DATE AND CAUSE OF DEATH. ONLY ONE CERTIFICATE OR STATEMENT IS REQUIRED FOR OUR RECORDS.

If the beneficiary is a minor or incompetent, the person having custody of the beneficiary should complete the form and give his/her address in Item 8A. If you are signing as the guardian or attorney-in-fact, please include a copy of the court appointment or power of attorney.

This completed form may be submitted by: UPLOAD:

Upload the form using our secure website at www.insurance.va.gov

MAIL:

VA Insurance Center

P.O. Box 7208

Philadelphia, PA 19101

5. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY (Please print)

8A. MAILING ADDRESS (MUST BE COMPLETED)

6. RELATIONSHIP TO INSURED

7. DATE OF BIRTH OF BENEFICIARY

8B. BENEFICIARY'S SOCIAL SECURITY NUMBER

8C. EMAIL ADDRESS

8D. DAYTIME TELEPHONE NUMBER

IMPORTANT -This form must be signed by the beneficiary, guardian, or fiduciary, in Item 9, in order for payment to be made. If the beneficiary cannot sign his/her name, but is competent to handle his/her own affairs, an "X", made by the beneficiary and signed by two disinterested witnesses, is acceptable.

CERTIFICATION: I certify that the above entries are true and correct to the best of my knowledge and belief.

9. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN (Sign in ink)

10. DATE

COMPLETE THE BANK ACCOUNT INFORMATION BELOW IN BLOCKS A THROUGH E TO RECEIVE THIS PAYMENT ELECTRONICALLY. THE ACCOUNT MUST BE IN THE NAME OF THE PERSON, ESTATE, OR TRUST DESIGNATED AS BENEFICIARY OR FIDUCIARY. IF THE BENEFICIARY IS A TRUST OR ESTATE, YOU MUST COMPLETE BOX G.

A. NAME OF FINANCIAL INSTITUTION

 

 

 

B. ROUTING TRANSIT NUMBER (NINE DIGIT FIELD)

 

 

 

 

 

 

 

 

 

 

 

C. TELEPHONE NUMBER OF FINANCIAL INSTITUTION

D. TYPE

 

 

 

 

E. DEPOSITOR ACCOUNT NUMBER

 

 

 

 

 

CHECKING

 

 

SAVINGS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. BENEFICIARY'S SOCIAL SECURITY NUMBER (Required for Direct Deposit)

G. EIN OR TIN NUMBER (FOR TRUST OR ESTATE ONLY)

 

 

 

 

 

 

 

 

 

 

 

 

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance Records-VA, and published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.

RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 5902). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 6 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. Comments on the accuracy of this burden or suggestions to decrease the burden may be included with the submission of this form or sent separately to VA Insurance Center, P.O. Box 7208, Philadelphia, PA 19101 or faxed to 1-888-748-5822.

IF YOU HAVE ANY QUESTIONS CONCERNING YOUR GOVERNMENT LIFE INSURANCE, PLEASE CALL OUR TOLL-FREE NUMBER 1-800-669-8477.

VA FORM

29-4125

SUPERSEDES VA FORM 29-4125, OCT 2019,

FEB 2020

WHICH WILL NOT BE USED.

How to Edit Va Form 29 4125 Online for Free

We were establishing the PDF editor with the concept of making it as easy to apply as possible. Therefore the process of filling in the wwwbenefits va gov insurance forms 29 4125 pfd will undoubtedly be smooth follow all of these actions:

Step 1: The first thing requires you to hit the orange "Get Form Now" button.

Step 2: Now you're on the form editing page. You may edit and add text to the file, highlight words and phrases, cross or check particular words, include images, insert a signature on it, erase unneeded areas, or eliminate them altogether.

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example of gaps in vaf 29 4125

The application will expect you to prepare the SIGNATURE OF BENEFICIARY, DATE, COMPLETE THE BANK ACCOUNT, B ROUTING TRANSIT NUMBER NINE, C TELEPHONE NUMBER OF FINANCIAL, D TYPE, E DEPOSITOR ACCOUNT NUMBER, CHECKING, SAVINGS, F BENEFICIARYS SOCIAL SECURITY, G EIN OR TIN NUMBER FOR TRUST OR, PRIVACY ACT NOTICE VA will not, IF YOU HAVE ANY QUESTIONS, VA FORM FEB, and SUPERSEDES VA FORM OCT WHICH box.

vaf 29 4125 SIGNATURE OF BENEFICIARY, DATE, COMPLETE THE BANK ACCOUNT, B ROUTING TRANSIT NUMBER NINE, C TELEPHONE NUMBER OF FINANCIAL, D TYPE, E DEPOSITOR ACCOUNT NUMBER, CHECKING, SAVINGS, F BENEFICIARYS SOCIAL SECURITY, G EIN OR TIN NUMBER FOR TRUST OR, PRIVACY ACT NOTICE VA will not, IF YOU HAVE ANY QUESTIONS, VA FORM FEB, and SUPERSEDES VA FORM OCT WHICH fields to complete

Step 3: Choose "Done". It's now possible to transfer your PDF form.

Step 4: Ensure you stay away from possible future worries by creating minimally two copies of your document.

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