Form VA Form 29-5767 VA Form 29-5767 Application for Payment of Matured Endowment

IN REPLY REFER TO:
FILE NUMBER:

We are pleased to tell you that your endowment policy
has matured, which means you
.
are entitled to the benefits of the policy now. The amount matured for your policy is
A check will be sent to you shortly. No action on your part is needed to receive this payment. You will also
receive a separate statement explaining any adjustments made.
If this method of payment is not satisfactory and you desire settlement under one of the installment options
available to you, do not cash the check. Instead, please return the check with this form within 31 days
indicating your option selection by completing the application on the reverse. Upon receipt of the check and
the completed form, we will comply with your request.
If you want to keep the check, DO NOT RETURN THIS APPLICATION.
If you want monthly installments, complete the application on the reverse and return it and the check to:
DEPARTMENT OF VETERANS AFFAIRS
ATTN: COLLECTIONS 292F
P.O. BOX 13399
PHILADELPHIA, PA 19101-3399
It will take approximately four (4) weeks to process your application. Be sure to mail your application to the
address exactly as indicated.

Chief, Insurance Claims Division

MATURED ENDOWMENT NOTIFICATION
QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL-FREE AT 1-800-669-8477
THE BEST DAYS TO CALL ARE WEDNESDAY AND THURSDAY.
OPERATORS ARE ON DUTY MONDAY THROUGH FRIDAY 8:30 AM TO 6 PM EASTERN TIME.
VA FORM
XXX XXXX

29-5767

OMB Control No. 2900-0159
Respondent Burden: 20 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR PAYMENT OF MATURED ENDOWMENT
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 as 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. Your obligation to respond is required to obtain monthly payments of your Government Life Insurance. The
responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN - We need this information to verify your eligibility for monthly payments of your Matured Endowment Government Life Insurance (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 20 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 . If desired, you can call 1-800-827-1000 to get information on where to send your comments about this form.

To receive payment of this policy in installments, this application must be completed, SIGNED BY THE INSURED, and returned promptly with
the endowment check to the VA Office shown on the reverse.
INSTRUCTIONS FOR COMPLETION OF APPLICATION:
• Item 1A should be checked and the number of installments selected (in multiples of 12) should be entered in the space provided if payment in a
limited number of monthly installments is desired.
• Item 1B should be checked if monthly payments for life are preferred.
• Item 1C should be checked if a combination of cash and installments (as described above) are chosen and Item 2 completed showing the amount
of cash desired and the installment option selected.
• If the selected installment plan would result in monthly payments of less than $10, the amount due will be paid in the largest number of
guaranteed monthly installments that are multiple of 12 and provide payments of at least $10.
• Item 3, Beneficiary Information - You may name as beneficiary(ies) any person, firm, corporation or legal entity, including your estate. If you
die before receiving all guaranteed monthly installments and no beneficiaries survive you, the remaining installments will be paid to your estate.
• Item 4, Check the block that shows how you wish any remaining guaranteed installments to be paid to the designated beneficiary.
Please call our toll-free number, 1-800-669-8477, for monthly installment rates or if you have any questions about installment payments.
1. PAY PROCEEDS OF THE POLICY (Check one)

2. COMPLETE IF 1C IS CHECKED
A. AMOUNT OF CASH

A. IN A LIMITED NUMBER OF MONTHLY INSTALLMENTS

$

(Specify Number)

B. TYPE OF INSTALLMENTS (Check one)

B. IN MONTHLY INSTALLMENTS CONTINUING DURING MY LIFETIME

MONTHLY INSTALLMENTS FOR

C. COMBINATION (Cash and any one of the installments selections)

MONTHS

(Specify Number)

(If checked complete Item 2)

INSTALLMENTS CONTINUING DURING MY LIFETIME

3. BENEFICIARY INFORMATION (Indicate below whether principal or contingent)
COMPLETE NAME AND ADDRESS OF EACH BENEFICIARY

(If a married woman, her own first and middle names and her
husband's last name must be given)

RELATIONSHIP

SHARE TO EACH BENEFICIARY

(Use fractions, such as 1/2, 2/3
"or "all")

4. PAY REMAINING UNPAID INSTALLMENTS TO DESIGNATED BENEFICIARY(IES) AS INDICATED ABOVE (Check one)
PRESENT VALUE OF ANY REMAINING INSTALLMENTS IN ONE SUM

CONTINUE MONTHLY INSTALLMENTS
6. DATE SIGNED

5. SIGNATURE OF INSURED

TO BE COMPLETED BY BENEFICIARY IF DIRECT DEPOSIT IS DESIRED
A. NAME OF FINANCIAL INSTITUTION

B. ROUTING TRANSIT NUMBER

C. ADDRESS OF FINANCIAL INSTITUTION

D. DEPOSITOR ACCOUNT NUMBER

E. TELEPHONE NUMBER OF FINANCIAL INSTITUTION

F. TYPE OF DEPOSITOR ACCOUNT
CHECKING

SAVINGS

DO NOT WRITE IN SPACES BELOW - FOR VA USE ONLY
PAYMENT AUTHORIZED BY:

VA FORM
XXX XXXX

29-5767

DATE SIGNED

AUDITED BY:

SUPERSEDES VA FORM 29-5767, JAN 2014,
WHICH WILL NOT BE USED.

DATE