Va Form 9957 Electronic Signature Details

If you are a veteran, then you may be eligible for certain benefits and services through the Department of Veterans Affairs. One such form that you may need to file in order to receive these benefits is VA Form 9957. This form is used to apply for Aid and Attendance benefits, which can provide financial assistance to veterans who require aid with daily living activities. The form can be complex, so it's important to understand what it is and how to complete it correctly. In this blog post, we will go over the basics of VA Form 9957 and provide some tips on how to fill it out correctly.

Here, you will discover quite a few information about va form 9957 PDF. Before you decide to complete the form, it's worth reading more details on it.

QuestionAnswer
Form NameVa Form 9957
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva form 9557, va9957 security form, va 9957, 9957 form

Form Preview Example

ACCESS FORM

PRIVACY ACT STATEMENT: The information is solicited under authority of Title 38, United States Code and Executive Order 9397 and is necessary to accomplish the action requested by the requester, including establishing, modifying or deleting a Customer Account. Furnishing the information on this form is voluntary; however, if the information is not furnished, we will be unable to take further action on your request.

NOTE: Information from this form is used to establish VA Accounts or to grant access to VA resources.

ARE YOU CURRENT ON YOUR SIGNED RULES OF BEHAVIOR; CYBER SECURITY AND PRIVACY TRAINING?

 

YES

NO

 

 

 

TYPE OF ACCESS

 

 

 

 

ZOS (Mainframe)

WINDOWS

EMAIL

 

 

 

 

UNIX

DATABASE

LAN ACCOUNT

 

 

 

 

USD

OTHER (Specify)

 

 

 

 

TYPE OF ACTION REQUESTED

CREATE NEW CUSTOMER

MODIFY EXISTING CUSTOMER

DELETE EXISTING CUSTOMER

2. CUSTOMER INFORMATION

A. NAME (Last, First, Middle Initial)

 

B. CUSTOMER ID

C. TELEPHONE NUMBER (Include Area Code)

 

 

 

 

D.STATION (FACILITY) NUMBER

E. MAIL ROUTING SYMBOL

F. JOB TITLE

 

 

OR STOP CODE

 

 

 

 

 

 

G. CONTRACTOR, OR IF TEMPORARY ACCESS, SHOW

H. CONTRACTOR OR OTHER GOVERNMENT ORGANIZATION, NAME EMPLOYER

EXPIRATION DATE (Month, day, year)

 

 

 

 

 

 

 

I. CONTRACTOR OR OTHER GOVERNMENT ORGANIZATION, OFFICE ADDRESS (Street, City, State, Zip Code)

J. ACTIVE DIRECTORY (AD) USERNAME

K. ACTIVE DIRECTORY (AD) DOMAIN

L. E-MAIL ADDRESS

NOTE: See reverse for instructions.

3. ACCESS REQUESTED

CHECK

NAME OF FUNCTIONAL TASK CODES; PROFILES, WEB

APPROPRIATE

BOX

SERVERS; UNIX ACCOUNTS; DATABASE OR OTHER

 

 

ACCESS

ADD

DELETE

 

 

 

 

DEFINE LEVEL OF ACCESS REQUESTED OR CONCURRING SYSTEM MANAGER OF

RECORD (SMR) DESIGNEE SIGNATURE AND TITLE (If required)

4. SIGNATURES

 

 

 

A. REQUESTING OFFICIAL & TITLE

B.DATE

 

 

C. APPROVING OFFICIAL & TITLE

D. DATE

 

 

E. SECOND APPROVING OFFICIAL & TITLE (If required)

F. DATE

 

 

G. NAME AND TITLE OF FACILITY POINT OF CONTACT OR INFORMATION SECURITY OFFICER

 

VA FORM

All prior editions of VA Form 9957 are not acceptable for submission.

Adobe LiveCycle Designer 7.1

APR 2008 9957

 

 

INSTRUCTIONS FOR COMPLETING THE ACCESS REQUEST FORM

1. Action Requested

ARE YOU CURRENT ON YOUR SIGNED RULES OF BEHAVIOR; CYBER SECURITY AND PRIVACY TRAINING? - If current, check "YES". If "NO" is checked then access form can not be processed.

TYPE OF ACCESS - check appropriate box.

TYPE OF ACTION REQUESTED - check appropriate box.

2. Customer Information

The following are detailed instructions on completing this form. This form must be completed electronically. Block 4, Signature Block, must have the name and title completed electronically, once the form is printed, all signatures must be ink signed.

a.Name - If VA employee, name must match name in PAID System.

b.Customer Identification (if for Austin main frame access enter seven (7) character Time Sharing Customer Identification.

c.Telephone Number

d.Facility (Station) Number/Suffix

e.Mail Routing Symbol or Mail Stop Code

f.Job Title - Use the title from Position Description

g.Expiration Date - Optional for Contractors and Students

h.Employer - Required for contractors and anyone other than a VA Employee

i.Office Address - Required

j.Active Directory (AD) Username - Required for all employees and contractors

k.Active Directory (AD) Domain - Required for all employees and contractors

l.E-mail Address - Required for all employees and contractors

3. Access Requested

Please contact your facility point of contact or Information Security Officer for a list of functional task codes and requirements.

4. Signatures

The person approving the access can not be the person requesting the access.

BACK OF VA FORM 9957, APR 2008, PAGE 2 OF 2

All prior editions of VA Form 9957 are not acceptable for submission.