Va Form 29 4125 – Fill Out and Use This PDF

All information requested in Section I is required. Enter the first, middle, last name of the insured veteran in Box 1. Enter the social security number in Box 2. Enter the insurance policy number in Box 3. Enter the date of death (MM/DD/YYYY) in Box 4.

If an individual is the beneficiary, complete Section II, then skip to Section VI.

Enter the first, middle, last name of the beneficiary in Box 5. Enter the social security number of the beneficiary in Box 6. Enter the date of birth of the beneficiary in Box 7. Enter the relationship to the insured in Box 8. Enter the email address in Box 11. Enter the daytime telephone number (include area code) in Box 12.

Enter the beneficiary's mailing address (number and street or P.O Box) in Box 9 and the mailing address (city, state, ZIP code) in Box 10. Both must be completed.

If a trust is the beneficiary, complete Section III, then skip to Section VI.

A copy of the trust agreement must be submitted with this form along with a voided check or copy of bank statement for the trust.

For Testamentary Trusts ONLY, provide a copy of the Will and court appointment documents (i.e., Letters Testamentary, Letters of Administration).

Enter the full name of the trust in Box 13. Enter the full name of the trustee in Box 14. Enter the mailing address (number and street or P.O. Box, city, state, ZIP code) in Box 15 (must be completed). Enter the daytime telephone number (include area code) in Box 16. Enter the email address in Box 17. Enter the trust agreement date (MM/DD/YYYY) in Box 18. Enter the EIN or TIN number for the trust in Box 19.

If a probated estate is the beneficiary, complete Section IV, then skip to Section VI.

Please include a copy of the appointment papers issued by the court (i.e., Letters Testamentary, Letters of Administration).

If the estate is not probated, complete VA Form 29-541, Certificate Showing Residence and Heirs of Deceased Veteran or Beneficiary in lieu of this form so VA can determine payment eligibility.

VA will notify each entitled heir to complete a VA Form 29-4125 once the heirs have been determined under the law.

Enter the full name of the estate in Box 20. Enter the full name of the court-appointed executor/administrator in Box 21. Enter the mailing address (number and street or P.O Box, city, state, ZIP code) in Box 22 (must be completed). Enter the daytime telephone number (include area code) in Box 23. Enter the email address in Box 24. Enter the EIN or TIN number for the estate in Box 25.

If an organization, charity, or other legal entity is the beneficiary, complete Section V, then skip to Section VI.

Please include letters of resolution/authority authorizing the representative to act/sign on behalf of the organization.

Enter the full name of the organization, charity, or legal entity in Box 26. Enter the full name of the authorized representative in Box 27. Enter the mailing address (number and street or P.O Box, city, state, ZIP code) in Box 28 (must be completed). Enter the daytime telephone number (include area code) in Box 29. Enter the email address in Box 30. Enter the EIN or TIN number for the organization, charity, or legal entity in Box 31.

All information requested in Section VI is required. Please provide your banking information in Section VI. The Department of Treasury has mandated that federal payments be issued via electronic funds transfer (EFT). Complete the bank account information to receive this payment electronically.

The account must be in the name of the person, trust, estate, organization/charity/legal entity of the designated beneficiary.

Enter the name of the financial institution in Box 32. Mark Checking or Savings for the type of account in Box 33. Enter the bank routing number (nine digit field) in Box 34. Enter the bank account number in Box 35.

The bank routing number is always 9 digits and appears between the |: symbols.

The bank account number varies in length and may contain dashes or spaces.

The ||: symbol indicates the end of the account number. |:123456789|: 1234. Check Number (Not needed).

Do not use a deposit slip to locate your banking information. This information can be different than your account information and could result in delaying payment.

By signing you certify that the entries are true and correct to the best of your knowledge and belief.

Sign in 36 (signature of beneficiary, guardian, attorney-in-fact, or fiduciary, or trustee, executor, or representative) and enter the date signed (MM/DD/YYYY) in 37.

An "X" for signature is acceptable if the beneficiary cannot sign his/her name but is competent to handle his/her own affairs, and "X" for a signature is acceptable when witnessed by two impartial people.

Impartial person is one not having a vested interest.

Enter the printed name of the first witness in 38A. Enter the mailing address of the first witness in 38B. Enter the telephone number of the first witness (include area code) in 38C. Enter the signature of the first witness in 38D. Enter the date signed (MM/DD/YYYY) in 38E. Enter the printed name of the second witness in 39A. Enter the mailing address of the second witness in 39B. Enter the telephone number of the second witness (include area code) in 39C. Enter the signature of the second witness in 39D. Enter the date signed (MM/DD/YYYY) in 39E.

You can submit the completed form by document upload or mailing. Document upload: Upload the form using the secure website at: https://insurance.va.gov/home/IDU. Mail to: Department of Veterans Affairs Insurance Center PO Box 5209 Janesville, WI 53547-5209. No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942).

This form should be used to submit all Veterans' Life Insurance claims except for Servicemember's Group Life Insurance (SGLI), Family Servicemember's Group Life Insurance (FSGLI) and Veteran's Group Life Insurance (VGLI).