21P-4718a Certificate of Balance on Deposit and Authorization to D

OMB Control No. 2900-0017
Respondent Burden: 3 Minutes
Expiration Date: XX/XX/20XX

CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS

(Pursuant to Title 38, U.S.C., Chapter 55 and Title 12, U.S.C., Chapter 35)
NOTE: PLEASE READ THE INSTRUCTIONS ON THE PAGE 2 BEFORE COMPLETING THE FORM.

SECTION I. CERTIFICATE - TO BE COMPLETED BY THE FINANCIAL INSTITUTION ONLY

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 1.526 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 Records - VA, published in the Federal Register. You are required to respond to obtain
or retain benefits (38 U.S.C. 5701). 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 3 minutes per respondent, per year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaing 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 an correspondence. Do not send your completed VA Form 21P-4718a to this eamil address.
1. NAME OF FIDUCIARY (First, middle, last)
2. NAME OF BENEFICIARY (First, middle, last)

(SEAL OR STAMP OF FINANCIAL INSTITUTION)

3. VA FILE NUMBER

C4B. ADDRESS OF FINANCIAL INSTITUTION

4A. NAME OF FINANCIAL INSTITUTION

4C. NAME AND TELEPHONE NUMBER OF FINANCIAL INSTITUTION CONTACT PERSON (Include Area Code)

5. DATA IN ITEM 6 WAS ACCURATE AS OF
(MM/DD/YYYY)

6. ACCOUNT INFORMATION
TYPE OF
ACCOUNT
(A)

ACCOUNT NUMBER

(State "None" if appropriate)
(B)

DEPOSITOR ACCOUNT
TITLE
(C)

BALANCE

(Include interest earned)
(D)

INTEREST EARNED/PAID SINCE
AMOUNT
(E)

DATE
(F)

CURRENT
INTEREST RATE
(G)

I CERTIFY THAT the foregoing amount(s) were on deposit to the credit of the above named fiduciary as shown by the record(s) of this financial institution.
7A. SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL
(Sign in ink)

VA FORM
XXX XXXX

21P-4718a

7B. TITLE OF CERTIFYING OFFICIAL

SUPERSEDES VA FORM 21-4718a, DEC 2021,
WHICH WILL NOT BE USED.

7C. DATE SIGNED

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SECTION II: AUTHORIZATION - TO BE COMPLETED BY THE FIDUCIARY ONLY

I hereby authorize the financial institution listed in Item 4A to verify the above Certificate information to VA, and/or to provide copies of any of the
financial records described above to VA.
8. I UNDERSTAND THAT:
a. This authorization is not required as a condition of doing business with any financial institution.
b. I have the right to obtain a copy of the record kept by the financial institution when financial records are disclosed as a result of this authorization.
VA has the right to request a court order to delay my receipt of a copy of the record.
c. VA is seeking disclosure of this information under the authority of Title 38 U.S.C. 5502(b) and will use the information in conducting an audit of
estates maintained on behalf of VA beneficiaries.
d. Transfer of records to other agencies of the federal government may only be made in accordance with the provisions of
title 12 U.S.C. 3412.
e. I have the right to withhold my consent to this disclosure.
f. I have the right to seek damages, attorneys' fees, and costs for any violation of the right to financial privacy act by either VA or the financial
institution.
9A. SIGNATURE OF FIDUCIARY (Sign in ink)

9B. DATE SIGNED

INSTRUCTIONS FOR COMPLETION OF VA FORM 21P-4718a
Section I - Certificate of Balance on Deposit
The fiduciary should complete Items 1, 2 and 3 before giving the form to the financial institution.
Only the financial institution should complete the rest of the items (4A through 7C) in this section.
The financial institution's seal or stamp must be placed in the space provided.
The financial institution should give the completed certificate to the fiduciary who will, in turn, submit it to VA with an
accounting.
Section II - Authorization to Disclose Financial Records
Only the fiduciary should complete this section.
The fiduciary may sign this section either before or after the Certificate section is completed by the financial institution.
(The fiduciary's signature in this section is not needed to allow the financial institution to complete the Certificate
section.)
An independent verification of financial records may be needed when VA audits the fiduciary's account. If so, VA will ask
for the information directly from the financial institution at a later time. At that time, VA will give the financial institution the
fiduciary's signed authorization.

VA FORM 21P-4718a, XXX XXXX

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