Get VA 21P-4706c 2019-2024
OMB Control No. 2900-0017 Respondent Burden 30 Minutes Expiration Date 07/31/2019 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 SECTION I - RECEIPTS DATE RECEIVED FROM Report income from or liquidation of each investment separately AMOUNT TOTAL RECEIPTS VA FORM JUL 2016 21P-4706c EXISTING STOCKS OF VA FORM 27-4706c OCT 2012 WILL NOT BE USED. SECTION II - EXPENDITURES TO WHOM PAID AND PURPOSE TOTAL EXPENDITURES VA FORM 21P-4706c JUL 2016 SECTION III - SUMMARY OF ACCOUNT CASH BALANCE FROM LAST ACCOUNTING TOTAL CASH BALANCE IN ESTATE INVESTMENTS Cost value BALANCE ON HAND LAST ACCOUNT ACQUIRED DURING PERIOD LIQUIDATED DURING PERIOD TOTAL ON HAND TOTAL VALUE OF ESTATE STATE OF COUNTY OF SS I being duly Sworn depose and say 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 there was on deposit in this Institution to the credit of this Fiduciary the following Checking Account Balance Account Number Savings Account Balance Including interest of paid during period of Statement of Account at. SEAL OR STAMP OF FINANCIAL INSTITUTION KIND OF BOND OR SECURITY INTEREST RATE DATE OF PURCHASE FACE VALUE COST control of the Fiduciary. SEAL OR STAMP OF FINANCIAL INSTITUTION KIND OF BOND OR SECURITY INTEREST RATE DATE OF PURCHASE FACE VALUE COST control of the Fiduciary. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL 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. Your obligation to respond is required to obtain or retain benefits. 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 We need this information to ensure proper administration of the beneficiary s estate. Title 38 United States Code Chapter 55 allows us to ask for this information* We estimate that you will need an average of 30 minutes to review the instructions find the information and complete this form* VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed* Valid OMB control numbers can be located on the OMB Internet Page at http //www.
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