VA Form 21P-4706c COURT APPOINTED FIDUCIARY'S ACCOUNT

OMB Control No. 2900-0017
Respondent Burden: 30 Minutes
Expiration Date: XXXXXXX

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)

(Date)

SECTION I - RECEIPTS
DATE

RECEIVED FROM
(Report income from or liquidation of each investment separately)

AMOUNT
$

TOTAL RECEIPTS
VA FORM
XXXXX

21P-4706c

EXISTING STOCKS OF VA FORM 27-4706c,
OCT 2012, WILL NOT BE USED.

$

SECTION II - EXPENDITURES
DATE

TO WHOM PAID AND PURPOSE

AMOUNT
$

TOTAL EXPENDITURES
VA FORM 21P-4706c, XXXX

$

SECTION III - SUMMARY OF ACCOUNT
CASH BALANCE FROM LAST ACCOUNTING
TOTAL RECEIPTS
TOTAL
TOTAL EXPENDITURES
CASH BALANCE IN ESTATE
INVESTMENTS (Cost value)
BALANCE ON HAND LAST ACCOUNT
ACQUIRED DURING PERIOD
TOTAL
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

day of

,

, there was on deposit in this Institution

to the credit of this Fiduciary the following:
Checking Account Balance $

Account Number

Savings Account Balance $

Account Number

Including interest of $

paid during period of Statement of Account at

%.

SEAL OR STAMP OF FINANCIAL INSTITUTION

(Signature and Title of Certifying Official)

VA FORM 21P-4706c, XXXXXX

SECTION V - CERTIFICATE AS TO SECURITIES
KIND OF BOND OR SECURITY

INTEREST
RATE

DATE OF
PURCHASE

FACE
VALUE
$

COST
$

I CERTIFY THAT the securities listed above were exhibited to me by the Fiduciary and are the property of the beneficiary and are in the custody and
control of the Fiduciary.
SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

DATE

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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21P-4706c, XXXXXX