Form 21-4718a Certificate of Bal. on Deposit and Auth. to Disclose Financial Record

NOTE: PLEASE READ THE INSTRUCTIONS ON THE REVERSE BEFORE COMPLETING THE FORM (1 NAME OF FIDUCIARY (First middle last)) (2 NAME OF BENEFICIARY (First middle last)) (3 V A FILE NUMBER) (4 A NAME OF FINANCIAL INSTITUTION) (4B ADDRESS 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 (Month day year) Enter 2 digit month 2 digit day and 4 digit year ) (7 A SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL This is a protected field ) (7B TITLE OF CERTIFYING OFFICIAL) (7C DATE SIGNED Enter 2 digit month 2 digit day and 4 digit year ) (9 A SIGNATURE OF FIDUCIARY This is a protected field ) (9B DATE SIGNED Enter 2 digit month 2 digit day and 4 digit year ) (ACCOUNT NUMBER (ACCOUNT NUMBER (AMOUNT (E)) (AMOUNT (E)) (BALANCE (Include interest earned) (BALANCE (Include interest earned) (CURRENT INTEREST RATE (G)) (CURRENT INTEREST RATE (G)) (DATE (F) Enter 2 digit month 2 digit day and 4 digit year ) (DATE (F) Enter 2 digit month 2 digit day and 4 digit year ) (DEPOSITOR ACCOUNT TITLE (DEPOSITOR ACCOUNT TITLE (Include interest earned) (Mo day yr ) (Pursuant to Title 38 U S C Chapter 55 and Title 12 U S C Chapter 35) (SEAL OR STAMP OF FINANCIAL INSTITUTION) (State "None" if appropriate) (State "None" if appropriate) (State "None" if appropriate) (TYPE OF ACCOUNT (A) Line 1 of 4) (TYPE OF ACCOUNT (A) Line 2 of 4) (TYPE OF ACCOUNT (A) Line 3 of 4) (TYPE OF ACCOUNT (A) Line 4 of 4) 1 800 827 1000 to get information on where to send comments or suggestions about this form 1 NAME OF FIDUCIARY (First middle last) 2 NAME OF BENEFICIARY (First middle last) 21 4718a 3 VA FILE NUMBER 4A NAME OF FINANCIAL INSTITUTION 4B ADDRESS 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 6 ACCOUNT INFORMATION 7A SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL 7B TITLE OF CERTIFYING OFFICIAL 7C DATE SIGNED 8 I UNDERSTAND THAT: 9A SIGNATURE OF FIDUCIARY 9B DATE SIGNED a This authorization is not required as a condition of doing business with any financial institution ACCOUNT ACCOUNT NUMBER AMOUNT An independent verification of financial records may be needed when VA audits the fiduciary's account If so 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 BALANCE beneficiary's estate Title 38 United States Code Chapter 55 allows us to ask for this information We 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 CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS complete the Certificate section ) complete this form VA cannot conduct or sponsor a collection of information unless a valid OMB Continued on Reverse control number is displayed You are not required to respond to a collection of CURRENT d Transfer of records to other agencies of the federal government may only be made in accordance with the provisions of Department of Veterans Affairs DEPOSITOR ACCOUNT e I have the right to withhold my consent to this disclosure estates maintained on behalf of VA beneficiaries estimate that you will need an average of 3 minutes to review the instructions find the information and 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 FEB 2009 financial institution the fiduciary's signed authorization I CERTIFICATE TO BE COMPLETED BY THE FINANCIAL INSTITUTION ONLY 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 I hereby authorize the financial institution named above to verify the above Certificate information to VA and/or to provide copies identified in the VA system of records 37VA27 VA Supervised Fiduciary/Beneficiary Records VA II AUTHORIZATION TO BE COMPLETED BY THE FIDUCIARY ONLY information if this number is not displayed Valid OMB control numbers can be located on the OMB information will be used by VA field examiners to determine whether an individual fiduciary is properly institution institution (The fiduciary's signature in this section is not needed to allow the financial institution to INSTRUCTIONS FOR COMPLETION OF VA FORM 21 4718a INTEREST EARNED/PAID SINCE INTEREST RATE Internet Page at: www whitehouse gov/omb/library/OMBINV VA EPA html#VA If desired you can call of any of the financial records described above to VA OMB APPROVED NO 2900 0017 Only the fiduciary should complete this section Only the financial institution should complete the rest of the items (4A through 7C) in this section PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any published in the Federal Register Your obligation to respond is required to obtain or retain benefits The Regulations 1 526 for routine uses (i e request from Congressman on behalf of a beneficiary) as RESPONDENT BURDEN: 3 Minutes RESPONDENT BURDEN: We need this information to ensure proper administration of the Section I Certificate of Balance on Deposit Section II Authorization to Disclose Financial Records source other than what has been authorized by the Privacy Act of 1974 or Title 5 Code of Federal successor fiduciary SUPERSEDES VA FORM 21 4718a MAR 2006 WHICH The fiduciary may sign this section either before or after the Certificate section is completed by the financial The fiduciary should complete Items 1 2 and 3 before giving the form to the financial institution The financial institution should give the completed certificate to the fiduciary who will in turn submit it to VA The financial institution's seal or stamp must be placed in the space provided TITLE title 12 U S C 3412 to furnish the requested information may result in the suspension of payments and/or appointment of a TYPE OF using and maintaining an accounting of the VA beneficiary's compensation or pension payments Failure VA FORM VA FORM 21 4718a FEB 2009 VA has the right to request a court order to delay my receipt of a copy of the record VA will ask for the information directly from the financial institution at a later time At that time VA will give the WILL NOT BE USED with an accounting