VA Form 27-0820d Report of Non-Receipt of Payment

OMB Control No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

REPORT OF NON-RECEIPT OF PAYMENT
NOTE - This form must be filled out in ink or on a computer, as it
becomes a permanent record in the veteran's folder.

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

1. VA OFFICE

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY

EVENING

6B. E-MAIL ADDRESS (If applicable)
7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT (Check)

9. ADDRESS OF PERSON CONTACTED

PERSONAL
TELEPHONE
10. TELEPHONE NUMBER OF PERSON CONTACTED

(Include Area Code)

I certify that I properly identified my caller using the ID Protocol.
11. BRIEF STATEMENT OF INFORMATION GIVEN AND RECEIVED:
DATE OF PAYMENT

AMOUNT OF PAYMENT

BENEFIT TYPE

PAYMENT SYSTEM

C&P

BDN

EDU

VETSNET

VR&E

POTENTIAL FRAUD

DIRECT DEPOSIT

YES

CHECK (not endorsed)

NO

C&P

BDN

EDU

VETSNET

DIRECT DEPOSIT

YES

CHECK (not endorsed)

NO

CHECK (endorsed)

C&P

BDN

DIRECT DEPOSIT

EDU

YES

VETSNET

CHECK (not endorsed)

NO

VR&E

ADDITIONAL INFORMATION
(Indicate financial hardship
in this space)

CHECK (endorsed)

VR&E

BENEFICIARY NAME:

PAYMENT TYPE

CHECK (endorsed)
BENEFICIARY SSN:

WAS AN UPDATE TO THE PAYMENT ADDRESS OR DIRECT DEPOSIT PROCESSED DURING THIS INTERACTION?
12. CERTIFICATION

PAYEE CODE:
YES

NO

I certify that I read the following statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA benefits. The primary purpose for gathering this
information or statement is to make an eligibility determination. It is subject to verification through computer matching programs with other agencies."
"If the original check is found or received, you must return the original check to the Treasury Department and await receipt of the replacement check. If both checks are negotiated, then you
will be responsible for the duplicate payment. You will receive a letter from the Debt Management Center with instructions concerning collection."
cc: POA (If applicable)
DIVISION OR SECTION

TRACER INPUT DATE

DIVISION OR SECTION

EXECUTED BY (Signature and title)

REGIONAL OFFICE

TO BE COMPLETED BY FINANCE ONLY

HARDSHIP REFUND AMOUNT

AUTHORIZED BY (For hardship cases only)

EXECUTED BY (Signature and title)

PRIVACY ACT NOTICE: The 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 5, Code of Federal Regulations 1.576 for
routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has
an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension,
Education and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The responses you submit are considered confidential (38
U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
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 2900-0734, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 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. 2900-0734 in any correspondence. Do not send your
completed VA Form 27-0820d to this email address.

VA FORM
XXX XXXX

27-0820d

SUPERSEDES VA FORM 27-0820d, DEC 2021,
WHICH WILL NOT BE USED.