Form VA Form 21-4709 VA Form 21-4709 Certificate As To Assets

OMB Approved No. 2900-0107
Respondent Burden: 12 mins.
VA FILE NUMBER

CERTIFICATE AS TO ASSETS
PRIVACY ACT INFORMATION: The 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 (i.e. civil or criminal law enforcement, congressional communications, epidemiological or
research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs
and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 37VA27, VA Supervised
Fiduciary/Beneficiary and General Investigative Records, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The
requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38
U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine whether to continue the fiduciary arrangement (38 U.S.C. Chapter 55). Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 12 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.
NAME OF FIDUCIARY (First-Middle-Last)

NAME OF VETERAN (First-Middle-Last)

NAME OF BENEFICIARY (First-Middle-Last)

LISTED SECURITIES ARE IN THE POSSESSION OF:

SECTION I - U.S. SAVINGS BONDS
LINE
NO.

DEPOSITOR ACCOUNT TITLE

SERIAL NUMBER

PURCHASE
DATE

PURCHASE PRICE

1
2
3
4
5
6
7
8
9
10

$

TOTAL

I CERTIFY THAT the U.S. Savings Bonds listed on lines 1 through _____ were exhibited to me by the above-named fiduciary as being the
property of the beneficiary, said bonds then and there being in the custody and control of the fiduciary.
DATE OF SIGNATURE

ADDRESS OF CERTIFYING OFFICIAL

SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

SECTION II - OTHER ASSETS
LINE
NO.

DEPOSITOR ACCOUNT

TYPE OF ASSET

PURCHASE DATE PURCHASE PRICE

INTEREST
RATE (If
applicable)

FACE VALUE
OR NUMBER
OF SHARES

1
2
3
4
5
TOTAL

$

I CERTIFY THAT the assets listed on lines 1 through _____ were exhibited to me by the above-named fiduciary as being the property of the
beneficiary, said assets then and there being in the custody and control of the fiduciary.
DATE OF SIGNATURE

ADDRESS OF CERTIFYING OFFICIAL

SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

NOTE: This certificate should be executed by a Bank Official or an authorized official or agent of the company which is surety on your bond.
However, if you are a court appointed fiduciary, the Judge or Clerk of the Court of your appointment may complete this certificate.
VA FORM
OCT 2005

21-4709

EXISTING STOCKS OF VA FORM 21-4709, JUN 2002,
WILL BE USED.