21P-4706c Court Appointed Fiduciary's Account

OMB Control No. 2900-0017
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

COURT APPOINTED FIDUCIARY'S ACCOUNT
NAME OF VETERAN (First-Middle-Last)

VA FILE NUMBER

C-

IN THE
IN THE MATTER OF THE ESTATE OF
(Minor or Incompetent)

}

COURT OF
STATEMENT OF ACCOUNT
to
(Date)

(Date)

SECTION I - RECEIPTS
DATE

RECEIVED FROM
(Report income from or liquidation of each investment separately)

AMOUNT
$

TOTAL RECEIPTS
VA FORM
XXX XXXX

21P-4706c

SUPERSEDES VA FORM 27-4706c, DEC 2021,
WHICH WILL NOT BE USED.

$
Page 1

SECTION II - EXPENDITURES
DATE

TO WHOM PAID AND PURPOSE

AMOUNT
$

TOTAL EXPENDITURES
VA FORM 21P-4706c, XXX XXXX

$
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SECTION III - SUMMARY OF ACCOUNT
CASH BALANCE FROM LAST ACCOUNTING
TOTAL RECEIPTS
TOTAL
TOTAL EXPENDITURES
CASH BALANCE IN ESTATE
INVESTMENTS (Cost value)
BALANCE ON HAND LAST ACCOUNT
ACQUIRED DURING PERIOD
TOTAL
LIQUIDATED DURING PERIOD
TOTAL ON HAND
TOTAL VALUE OF ESTATE

$
$

$
$

}

STATE OF
COUNTY OF

$
$

$

$
$

$
$

SS
being duly Sworn, depose and say

I
of the estate of
who is now residing at

that this is a full and true account of the beneficiary's estate for the period stated, to the best of my knowledge and belief.

(Signature of Fiduciary)

Subscribed and Sworn to before me this

day of

,

A.D.

(Signature and Title)

SECTION IV - CERTIFICATE OF BALANCE ON DEPOSIT
NAME AND ADDRESS OF INSTITUTION

I CERTIFY THAT on the

day of

,

, there was on deposit in this Institution

to the credit of this Fiduciary the following:
Checking Account Balance $

Account Number

Savings Account Balance $

Account Number

Including interest of $

paid during period of Statement of Account at

%.

SEAL OR STAMP OF FINANCIAL INSTITUTION

(Signature and Title of Certifying Official)

VA FORM 21P-4706c, XXX XXXX

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SECTION V - CERTIFICATE AS TO SECURITIES
KIND OF BOND OR SECURITY

INTEREST
RATE

DATE OF
PURCHASE

FACE
VALUE

COST
$

$

I CERTIFY THAT the securities listed above were exhibited to me by the Fiduciary and are the property of the beneficiary and are in the custody and
control of the Fiduciary.
SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

DATE

ADDRESS OF CERTIFYING OFFICIAL

NOTE: This Certificate may be executed by the Judge or Clerk of Court of your appointment, an official of the safety deposit company or bank
wherein you have securities in lock box, or by any authorized official or agent of the company which is surety on your bond.
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized by the Privacy Act of 1974 or Title 5, Code of
Federal Regulations 1.576 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
Records - VA, published in the Federal Register. You are required to respond to obtain or retain benefits per 38 U.S.C § 501. The information will be used by VA field examiners to determine
whether an individual fiduciary is properly using and maintaining an accounting of the VA beneficiary's compensation or pension payments. Failure to furnish the requested information may
result in the suspension of payments and/or appointment of a successor fiduciary.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0017, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0017 in any correspondence. Do not send your completed VA Form 21P-4706c to this email address.
VA FORM 21P-4706c, XXX XXXX

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