Form VA Form 21-4706 VA Form 21-4706 Annual-Final Report and Accounting

OMB Approval No. 2900-0017
Respondent Burden: 30 Minutes

IN THE_______________________________COURT.
STATE OF____________________
COUNTY OF____________________

}

SS:

IN THE MATTER OF
File No.____________________________

___________________________Reporting and Accounting
TO THE HONORABLE COURT:
1. This is a full and true statement of account in the matter of______________________________________
_______________________________, covering the period from the______________________________day
of_________________________, to the____________________day of_______________________________
I have on file a surety bond approved by the Court in the penal sum of $_______________________with
the__________________________________________ Company as surety.
I have on file a personal surety bond approved by the Court in the penal sum of $___________________.
The names and addresses of personal sureties are:
______________________________________
_________________________________________________
______________________________________
_________________________________________________
2. MONEY RECEIVED
DATE

RECEIVED FROM
(List each source separately)

AMOUNT
$

TOTAL AMOUNT RECEIVED $
VA FORM
MAR 2006

21-4706

3. MONEY SPENT
DATE

AMOUNT

TO WHOM PAID AND PURPOSE
$

$

TOTAL AMOUNT SPENT

4. SUMMARY:
Cash brought forward from last accounting
Money received from all sources
TOTAL
Less total money spent
Cash balance in estate
Total of all investment (cost)
TOTAL VALUE OF ESTATE

$
$
$
$___________
___________
5.

CERTIFICATION OF BALANCE ON DEPOSIT:
I CERTIFY THAT on the ____________________day of ___________, _________, the last day of the period
covered by this accounting, there was on deposit in this institution to the credit of this Fiduciary the following
balance:
NAME AND ADDRESS OF INSTITUTION

ACCOUNT

SEAL OR STAMP OF FINANCIAL
INSTITUTION

*SAVINGS

CHECKING
Acct. No.:

Acct. No.:

$

$
SIGNATURE AND TITLE OF CERTIFYING BANK
OFFICER

*Including interest of $
Paid during the period covered by the
accounting.

NAME AND ADDRESS OF INSTITUTION

ACCOUNT
*SAVINGS

CHECKING
Acct. No.:

Acct. No.:

$

$
SIGNATURE AND TITLE OF CERTIFYING BANK
OFFICER

*Including interest of $
Paid during the period covered by the
accounting.
ACCOUNT

NAME AND ADDRESS OF INSTITUTION
*SAVINGS

CHECKING
Acct. No.:

$
SIGNATURE AND TITLE OF CERTIFYING BANK
OFFICER

Acct. No.:

$

*Including interest of $
Paid during the period covered by the
accounting.

6. CERTIFICATION OF INVESTMENTS (to be executed by Judge or Clerk of Court, a bank official or
authorized official or agent of the corporate surety on fiduciary bond):

INTEREST DATE OF
RATE PURCHASE

KIND OF BOND OR SECURITY

FACE
VALUE

COST

$
I CERTIFY That the securities listed herein were exhibited to me by the Fiduciary as being the property of
the ward and in the custody and control of the Fiduciary.
TOTAL COST

STATE OF
COUNTY OF
Subscribed and sworn to before me this
day of

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SS:

Signature of Fiduciary

Address of Fiduciary

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 38 Code of Federal Regulations 1.526
for routine uses as identified in VA’s system of records, 37VA27,VA Supervised Fiduciary and Beneficiary
Records-VA, published in the Federal Register. Your obligation to respond is required to obtain or retain
benefits. The information relating to funds derived from Department of Veterans Affairs benefit payments is
requested under authority of Title 38, United States Code, chapter 55. The information will be used to assure
the proper administration of the beneficiary’s income and estate. Failure to furnish the requested information
may result in the suspension of payments and/or the appointment of a successor fiduciary.

Court

on page

Judge of

Recorded in Book

, A.D.
day of
On the

ALLOWED
Filed

STATE OF

In the matter of the estate of

In

No.

COUNTY OF

Incompetent
Minor,

COURT,

RESPONDENT BURDEN: We need this information to ensure proper administration of the beneficiary’s
estate.Title 38, United States Code, 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. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.