VA Form 21-4718a Certificate of Balance on Deposit and Authorization to D

OMB APPROVED NO. 2900-0017
RESPONDENT BURDEN: 3 Minutes

CERTIFICATE OF BALANCE ON DEPOSIT AND AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS
(Pursuant to Title 38, U.S.C., Chapter 55 and Title 12, U.S.C., Chapter 35)

NOTE: PLEASE READ THE INSTRUCTIONS ON THE REVERSE BEFORE COMPLETING THE FORM.

I. CERTIFICATE - TO BE COMPLETED BY THE FINANCIAL INSTITUTION ONLY
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
1.526 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 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 3 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.
1. NAME OF FIDUCIARY (First, middle, last)

2. NAME OF BENEFICIARY (First, middle, last)

(SEAL OR STAMP OF FINANCIAL INSTITUTION)

3. VA FILE NUMBER

C4A. 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
(Mo., day, yr.)

6. ACCOUNT INFORMATION
TYPE OF
ACCOUNT
(A)

ACCOUNT NUMBER
(State "None" if appropriate)
(B)

DEPOSITOR ACCOUNT
TITLE
(C)

BALANCE
(Include interest earned)
(D)

INTEREST EARNED/PAID SINCE
AMOUNT
(E)

DATE
(F)

CURRENT
INTEREST RATE
(G)

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.
7A. SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL

7B. TITLE OF CERTIFYING OFFICIAL

7C. DATE SIGNED

II. AUTHORIZATION - TO BE COMPLETED BY THE FIDUCIARY ONLY
I hereby authorize the financial institution named above to verify the above Certificate information to VA, and/or to provide copies
of any of the financial records described above to VA.
8. I UNDERSTAND THAT:
a. This authorization is not required as a condition of doing business with any financial institution.
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. VA has the right to request a court order to delay my receipt of a copy of the record.
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 estates maintained on behalf of VA beneficiaries.
d. Transfer of records to other agencies of the federal government may only be made in accordance with the provisions of
title 12 U.S.C. s
s 3412.
e. I have the right to withhold my consent to this disclosure.
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 institution.
9A. SIGNATURE OF FIDUCIARY

VA FORM
FEB 2009

21-4718a

9B. DATE SIGNED

SUPERSEDES VA FORM 21-4718a, MAR 2006, WHICH
WILL NOT BE USED.

Continued on Reverse

INSTRUCTIONS FOR COMPLETION OF VA FORM 21-4718a
Section I - Certificate of Balance on Deposit
The fiduciary should complete Items 1, 2 and 3 before giving the form to the financial institution.
Only the financial institution should complete the rest of the items (4A through 7C) in this section.
The financial institution’s seal or stamp must be placed in the space provided.
The financial institution should give the completed certificate to the fiduciary who will, in turn, submit it to VA
with an accounting.
Section II - Authorization to Disclose Financial Records
Only the fiduciary should complete this section.
The fiduciary may sign this section either before or after the Certificate section is completed by the financial
institution. (The fiduciary’s signature in this section is not needed to allow the financial institution to
complete the Certificate section.)
An independent verification of financial records may be needed when VA audits the fiduciary’s account. If so,
VA will ask for the information directly from the financial institution at a later time. At that time, VA will give
the financial institution the fiduciary’s signed authorization.