VA Form 21-4706b Federal Fiduciary's Account

OMB Control No. 2900-0017
Respondent Burden: 27 Minutes

FEDERAL FIDUCIARY’S ACCOUNT
VA FIDUCIARY ACTIVITY

NAME AND ADDRESS OF FIDUCIARY

FROM

TO

NAME OF VETERAN (First-Middle-Last)

NAME OF BENEFICIARY (If not veteran)

VA FILE NUMBER

C-

SECTION I - STATEMENT OF ACCOUNT
INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Activity. Show
monthly amount where indicated, in addition to amount for accounting period. Attach a completed Certification of Funds on Deposit,
(VA Form 21-4718a) if this accounting shows any funds on deposit.
IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.

ACCOUNTING PERIOD
FROM

TO

IMPORTANT - The fiduciary should keep receipts and other documentation of expenses because VA may need to examine them during the audit of
this accounting.
1. MONEY RECEIVED
4. ASSETS AT END OF PERIOD*
ITEM

DESCRIPTION

AMOUNT

A

TOTAL ESTATE AT BEGINNING OF PERIOD

B

AMOUNT
RECEIVED
FROM VA

NO. OF MONTHS

C

AMOUNT
RECEIVED
FROM
SOCIAL
SECURITY

NO. OF MONTHS

DESCRIPTION

A

CASH ON HAND (NOT ON DEPOSIT
IN BANK)

B

AMOUNT IN CHECKING ACCOUNT

C

AMOUNT IN SAVINGS ACCOUNT

$

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

INTEREST EARNED ON DEPOSITS

E

AMOUNT RECEIVED FROM OTHER SOURCES
(List in Items 1E thru 1H)

TOTAL PURCHASE PRICE OF
SAVINGS BONDS LISTED ON
REVERSE (Complete reverse for total in
this field)

D

(1) IF PURCHASE PRICE OF SAVINGS
BONDS CHANGED FROM THE LAST
ACCOUNTING PERIOD, WERE
ADDITIONAL BONDS PURCHASED?
YES

NO

(2) WERE SAVINGS BONDS CASHED
DURING THE ACCOUNTING PERIOD?

YES

*TOTAL RECEIVED (ADD LINES 1A THRU 1H)

$

2. MONEY SPENT
NO. OF MONTHS

AMOUNT

MONTHLY AMT.

D

F
G
H
I

$

ITEM

NO

OTHER (Specify)

E

MONTHLY AMT.

A

ROOM AND
BOARD/RENT

B
C

CLOTHING
ENTERTAINMENT
NO. OF MONTHS

MONTHLY AMT.

D

PERSONAL
USE
DEPENDENT(S)
SUPPORT

NO. OF MONTHS

MONTHLY AMT.

E
F
G
H
I
J
K
L
M

FIDUCIARY FEE IF APPROVED BY VA
OTHER (Specify)

$

TOTAL SPENT (ADD LINES 2A THRU 2L)

3. TOTAL ESTATE AT END OF PERIOD
(SUBTRACT 2M FROM 1I)

5. TOTAL ASSETS
(MUST EQUAL ITEM 3)

$

6. REMARKS (If needed you may continue in "Remarks" section on reverse
or, if necessary, attach additional sheets and key responses to item
numbers.)

$
$

* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21-4703), this is a complete accounting of all funds I received for the beneficiary.

I CERTIFY THAT this is a true account of the beneficiary’s estate for the period stated, to the best of my knowledge and belief.
7. DATE

8. SUBMITTED BY (Signature and title of fiduciary)

9. DATE APPROVED

10. APPROVED BY (Signature and title of VA official)

VA FORM
MAR 2006

21-4706b

EXISTING STOCKS OF VA FORM 21-4706b, NOV 2002,
WILL BE USED.

(Continued on Reverse)

6. REMARKS (Continued)

LINE
NO.

SERIAL NUMBER

SECTION II - CERTIFICATION OF U.S. SAVINGS BONDS
DATE OF
PURCHASE LINE
SERIAL NUMBER
PURCHASE
PRICE
NO.

1.

11.

2.

12.

3.

13.

4.

14.

5.

15.

6.

16.

7.

17.

8.

18.

9.

19.

10.

20.

DATE OF
PURCHASE

PURCHASE
PRICE

I CERTIFY THAT the savings bonds listed above are the property of the estate of the beneficiary and are in my custody and
control.
SIGNATURE OF FIDUCIARY

DATE

PRIVACY ACT INFORMATION: The VA will not disclose information on the 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. request from Congressman on behalf of a beneficiary) as identified in the VA system of records,
37VA27, VA Supervised Fiduciary/Beneficiary and General Investigative Records, and published in the Federal Register. Your obligation to respond is required to
obtain or retain benefits. The information will be used to ensure 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.
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 27 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/library/omb/OMBINVC.html#VA. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.