9. BACKGROUND INFORMATION
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 https://reginfo.gov/public/do/PRAMain.
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, published in the Federal Register. You are required to respond (38 U.S.C.
5701) 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.
SIGNATURE OF FIDUCIARY (Sign in ink)
DATE
I CERTIFY THAT the savings bonds listed above are the property of the estate of the beneficiary and are in my custody and control.
SECTION II - CERTIFICATION OF U.S. SAVINGS BONDS
LINE
NO.
2.
3.
1.
SERIAL NUMBER
DATE OF
PURCHASE
4.
5.
LINE
NO.
PURCHASE
PRICE
SERIAL NUMBER
DATE OF
PURCHASE
PURCHASE
PRICE
6.
7.
8.
9.
10.
Answer the questions below if you are an individual appointed to serve as fiduciary for the beneficiary named on the reverse side of this form.
The questions pertain to your personal criminal and credit history. Failure to provide a response may impact your ability to serve as a VA fiduciary.
You are not required to respond to these questions if you are serving as VA fiduciary in one of the following capacities for the beneficiary named on the
reverse:
• administrator of a facility
• company or corporation
• court-appointed fiduciary who is also appointed by VA
I certify that during this accounting period, I have not been convicted of any offense under Federal or State law, which resulted in imprisonment for more
than one year. I understand the Department of Veterans Affairs may obtain my criminal background history to verify my response. Initial the box below
to certify and acknowledge this information.
I certify that during this accounting period, I did not default on a debt, was not the subject of collection action by a creditor and did not file bankruptcy.
To the best of my knowledge, no adverse credit information was reported to a credit bureau because I was unable to meet my personal financial
obligations. I understand the Department of Veterans Affairs may obtain my credit history report to verify my response. Initial the box below to certify
and acknowledge this information.
10. EXPLANATION OF BACKGROUND INFORMATION (If necessary)
VA FORM 21P-4706b, DEC 2019
