21P4706b VA FIDUCIARY'S ACCOUNT

OMB Control No. 2900-0017
Respondent Burden: 27 Minutes
Expiration Date: XXXXXXXX

VA FIDUCIARY'S ACCOUNT
NAME AND ADDRESS OF FIDUCIARY

VA FIDUCIARY HUB

FROM

TO

NAME OF VETERAN (First-Middle-Last)

NAME OF BENEFICIARY (If not veteran)

VA FILE NUMBER

C-

SECTION I - STATEMENT OF ACCOUNT

INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Hub. Show monthly
amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the
entire accounting period to support the transactions noted on this accounting.
IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.

ACCOUNTING PERIOD
FROM

TO

IMPORTANT - The fiduciary must account for all funds received on behalf of the beneficiary as VA fiduciary, representative payee for SSA benefits, or in any other
fiduciary capacity. The fiduciary must keep receipts and other documentation of expenses because VA may need to examine them during the audit of this accounting.

1. MONEY RECEIVED
A

AMOUNT
RECEIVED
FROM VA

C

AMOUNT
RECEIVED
FROM
SOCIAL
SECURITY

E
F
G
H
I

AMOUNT

TOTAL ESTATE AT BEGINNING OF PERIOD

B

D

NO. OF MONTHS

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

$

ITEM

DESCRIPTION

A
B

TOTAL AMOUNT OF SAVINGS
ACCOUNT(S)

C

TOTAL AMOUNT OF
CERTIFICATE(S) OF DEPOSIT

$

TOTAL PURCHASE PRICE OF
SAVINGS BONDS LISTED ON
REVERSE (Complete reverse for

total in this field)

D

AMOUNT RECEIVED FROM OTHER SOURCES

(1) WERE ADDITIONAL BONDS
PURCHASED DURING THIS
ACCOUNTING PERIOD?
YES

NO

(2) WERE SAVINGS BONDS CASHED
DURING THIS ACCOUNTING
PERIOD?

(List in Items 1E thru 1H)

YES

*TOTAL RECEIVED (ADD LINES 1A THRU 1H)

AMOUNT

TOTAL AMOUNT OF CHECKING
ACCOUNT(S)

INTEREST EARNED ON DEPOSITS

$

E

2. MONEY SPENT

NO

OTHER (List outstanding checks or other
issues that impact the total assets.)

NO. OF MONTHS MONTHLY AMT.

A

ROOM AND
BOARD/RENT

B
C

CLOTHING
ENTERTAINMENT

D

PERSONAL
USE

NO. OF MONTHS MONTHLY AMT.

E

DEPENDENT
(S) SUPPORT

NO. OF MONTHS MONTHLY AMT.

F
G
H
I
J
K
L
M

4. ASSETS AT END OF PERIOD*

DESCRIPTION

ITEM

$

5. TOTAL ASSETS

(MUST EQUAL ITEM 3)

$

6. REMARKS (If needed you may attach additional sheets and key

responses to item numbers.)

FIDUCIARY FEE IF APPROVED BY VA
OTHER (Specify)

TOTAL SPENT (ADD LINES 2A THRU 2L)
3. TOTAL FUNDS UNDER MANAGEMENT AT
END OF PERIOD (SUBTRACT 2M FROM 1I)

$
$

* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-4703), this is a complete accounting of all funds I received for the beneficiary.
I CERTIFY THAT this is a true account of the beneficiary's estate for the period stated, to the best of my knowledge and belief.
7. DATE
VA FORM
XXXX

8. SUBMITTED BY (Signature and title of fiduciary) (Sign in ink)

21P-4706b

SUPERSEDES VA FORM 21-4706b, JUL 2016,
WHICH WILL NOT BE USED.

(Continued on Reverse)

9. BACKGROUND INFORMATION
Answer the questions below if you are an individual appointed to serve as fiduciary for the beneficiary named on the reverse side of this form.
The questions pertain to your personal criminal and credit history. Failure to provide a response may impact your ability to serve as a VA fiduciary.
You are not required to respond to these questions if you are serving as VA fiduciary in one of the following capacities for the beneficiary named on the
reverse:
• administrator of a facility
• company or corporation
• court-appointed fiduciary who is also appointed by VA
I certify that during this accounting period, I have not been convicted of any offense under Federal or State law, which resulted in imprisonment for more
than one year. I understand the Department of Veterans Affairs may obtain my criminal background history to verify my response. Initial the box below
to certify and acknowledge this information.

I certify that during this accounting period, I did not default on a debt, was not the subject of collection action by a creditor and did not file bankruptcy.
To the best of my knowledge, no adverse credit information was reported to a credit bureau because I was unable to meet my personal financial
obligations. I understand the Department of Veterans Affairs may obtain my credit history report to verify my response. Initial the box below to certify
and acknowledge this information.

10. EXPLANATION OF BACKGROUND INFORMATION (If necessary)

LINE
NO.

SERIAL NUMBER

DATE OF
PURCHASE

PURCHASE
PRICE

LINE
NO.

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

SERIAL NUMBER

DATE OF
PURCHASE

PURCHASE
PRICE

SECTION II - CERTIFICATION OF U.S. SAVINGS BONDS
I CERTIFY THAT the savings bonds listed above are the property of the estate of the beneficiary and are in my custody and control.
SIGNATURE OF FIDUCIARY (Sign in ink)

DATE

PRIVACY ACT INFORMATION: The VA will not disclose information on the form to any source other than what has been authorized under the Privacy Act of
1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e. request from Congressman on behalf of a beneficiary) as identified in the VA system of
records, 37VA27, VA Supervised Fiduciary/Beneficiary and General Investigative Records, published in the Federal Register. You are required to respond (38 U.S.C.
5701) to obtain or retain benefits. The information will be used to ensure the proper administration of the beneficiary's income and estate. Failure to furnish the
requested information may result in the suspension of payments and/or the appointment of a successor fiduciary.
RESPONDENT BURDEN: We need this information to ensure proper administration of the beneficiary's estate. Title 38, United States Code allows us to ask for this
information. We estimate that you will need an average of 27 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.
VA FORM 21P-4706b, XXXX