Form VA Form 29-586 VA Form 29-586 Certification of Change or Correction of Name Government

OMB Control No. 2900-0679
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/XXXX

CERTIFICATION OF CHANGE OR CORRECTION OF NAME
GOVERNMENT LIFE INSURANCE
NOTICE: We have received a communication that indicates your name as it appears on our insurance records should be changed.
If it is different than that shown below, please complete and return this form.
1. NAME AND ADDRESS OF INSURED

2. INSURANCE FILE NUMBER
3. SOCIAL SECURITY NUMBER

PART I - TO BE COMPLETED BY INSURED
5. ADDRESS (Complete only if your address is different than that
4. CHANGE OR CORRECT MY NAME (Type or print)
shown in Item 1)

6. REASON FOR CHANGE OR CORRECTION OF NAME
MARRIAGE

CORRECTION

DIVORCE OR ANNULMENT

OTHER (Specify)

I CERTIFY that I am the insured named in the policy/policies, under the above file number.
7. SIGNATURE OF INSURED

8. DATE

PART II - TO BE COMPLETED BY WITNESSES
(To be completed only if change of name is other than marriage, divorce, annulment, or for correction of name.
Two witnesses are required.)
I CERTIFY that I have personally known this insured and know him/her to be one and the same person; that to the best of my
knowledge and belief the change or correction of name is requested for the reason specified.
SIGNATURE OF WITNESS
(A)

ADDRESS OF WITNESS
(B)

DATE
(C)

PENALTY: The law provides that whoever makes any statement of a material fact, knowing it to be false, shall be punished by a fine
or imprisonment, or both.
IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, CALL US TOLL FREE AT 1-800-669-8477.
PRIVACY ACT INFORMATION: 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, 36VA00,
Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA, published in the Federal Register. Completion of this form is
required to retain benefits. The responses you submit are considered confidential (38 U.S.C. 5710).
RESPONDENT BURDEN: The form is used by the insured as a certification of change or correction of name. The information on the form is
required by law, USC 1904 and 1942. We estimate that you will need an average of 10 minutes to review the instructions, find the information, and
complete the 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.
VA FORM
XXX XXXX

29-586

SUPERSEDES VA FORM 29-586, SEP 2006,
WHICH WILL NOT BE USED.