VBA 26-10280a Statement Of A Person Claiming Loan Fee Refund Due a Dec

OMB Approved No. 2900-0910
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/20XX

STATEMENT OF A PERSON CLAIMING LOAN FEE REFUND
DUE A DECEASED SURVIVING SPOUSE
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 5, Code
of Federal Regulations 1.526 for routine uses (i.e., the record of an individual who is covered by this system may be disclosed to a member of Congress or staff person acting for the member
when the request is made on behalf of the individual) identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records,
Specifically Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, published in the Federal Register. You are not required to claim the refund due the decent, but if
you do so, you must provide the information requested on this form. Failure to provide this information may delay or prevent processing of your request.
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 2900-0910, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 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 vapra@va.gov. Please refer to OMB Control No. 2900-0910 in any correspondence. Do not send your completed VA Form 26-10280a to this email address.

1. NAME OF DECEASED SURVIVING SPOUSE

2. DECEDENT'S SOCIAL SECURITY NUMBER

3. NAME OF PERSON CLAIMING REFUND

4. YOUR SOCIAL SECURITY NUMBER

5. YOUR HOUSE ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

PART I: ALL PERSONS MUST COMPLETE THIS PART.
6. CHECK THE ONE BOX THAT APPLIES TO YOU. YOU MUST COMPLETE PARTS II AND III BELOW. SEE INSTRUCTIONS.
A. Court-appointed or certified personal representative (see instructions for more information). Attached a court certificate showing your appointment.
B. Person, other than A, claiming refund for the decedent's estate.
7. IF YOU SELECTED LINE B IN ITEM 6, PLEASE INDICATE YOUR RELATIONSHIP TO THE DECEDENT HERE

PART II: ALL PERSONS MUST COMPLETE THIS PART.
YES

NO

8. DID THE DECEDENT LEAVE A WILL?
9a. HAS A COURT APPOINTED A PERSONAL REPRESENTATIVE FOR THE ESTATE OF THE DECEDENT?
9b. IF YOU ANSWERED "NO" TO ITEM 9a, WILL ONE BE APPOINTED?
IF YOU ANSWERED "YES" TO ITEM 9a OR 9b, THE PERSONAL REPRESENTATIVE MUST FILE FOR THE REFUND.
10. AS THE PERSON CLAIMING THE REFUND FOR THE DECEDENT'S ESTATE, WILL YOU PAY OUT THE REFUND
ACCORDING TO THE LAWS OF THE STATE WHERE THE DECEDENT WAS A LEGAL RESIDENCE?
IF YOU ANSWERED "NO" TO ITEM 10, A REFUND CANNOT BE MADE UNTIL YOU SUBMIT A COURT CERTIFICATE
SHOWING YOUR APPOINTMENT AS PERSONAL REPRESENTATIVE OR OTHER EVIDENCE THAT YOU ARE ENTITLED
UNDER STATE LAW TO RECEIVE THE REFUND.

PART III: SIGNATURE AND VERIFICATION. ALL PERSONS MUST COMPLETE THIS PART.
I request a refund of loan fees overpaid by or on behalf of the decedent in connection with a VA-guaranteed, insured or direct loan. Under penalties
of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, it is true, correct, and complete.
11a. SIGNATURE OF PERSON CLAIMING REFUND

11b. DATE (MM/DD/YYYY)

12. PHONE NUMBER

FEDERAL STATUTES PROVIDE SEVERE PENALTIES FOR FRAUD, INTENTIONAL MISREPRESENTATION, CRIMINAL
CONNIVANCE OR CONSPIRACY PURPOSED TO INFLUENCE THE ISSUANCE OF ANY GUARANTY OR INSURANCE BY THE
SECRETARY OF VETERAN AFFAIRS (e.g., 18 U.S.C. § 1001, 372 and 287)

VA FORM
XXX 20XX

26-10280a

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INSTRUCTIONS FOR VA FORM 26-10280a
Persons seeking to claim a refund of a loan fee paid in connection with a VA-guaranteed, insured or direct loan that is owed to a
deceased Surviving Spouse must complete VA Form 26-10280a, Statement of a Person Claiming Loan Fee Refund Due a Deceased
Surviving Spouse. Persons seeking to claim a refund that is owed to a deceased Veteran or Service Member should refer to VA Form
26-10280, Statement of a Person Claiming Loan Fee Refund Due a Deceased Veteran or Service Member.
Specific Instructions
Line 6a. - Check the box on line 6A only if you are the decedent's court-appointed or certified personal representative claiming a
refund for the decedent. For purposes of this form, a personal representative is the executor or administrator of the
decedent's estate, as appointed or certified by the court. You must attach a copy of the court certificate showing your
appointment. A copy of the decedent's will cannot be accepted as evidence that you are the personal representative.
Line 6b. - Check the box on line 6B if there is not a court-appointed or certified personal representative. You must also complete line
7 in Part I.

VA FORM 26-10280a, XXX 20XX

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