Form 29-596 Certification of Change for Correction of Name - Governm

OMB Control No. 2900-0679
Respondent Burden: 10 minutes
Expiration Date: XXXXXXXX

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
4. CHANGE OR CORRECT MY NAME (Type or print)

5. ADDRESS (Complete only if your address is different than that

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 (Sign in ink)

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
(Sign in ink)
(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, 36VA29, Veterans and Uniformed Services Personnel
Programs of U.S. Government Life Insurance - 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
VA FORM
XXXX

29-586

SUPERSEDES VA FORM 29-586, FEB 2019,
WHICH WILL NOT BE USED.