Excersise

LavenderG

VBA-21P-4706b-ARE2.pdf

Home >Mathematics homework help >Statistics homework help >Excersise

NAME AND ADDRESS OF FIDUCIARY VA FIDUCIARY HUB

DESCRIPTION AMOUNT

ITEM 1. MONEY RECEIVED

TOTAL ESTATE AT BEGINNING OF PERIOD

VA FORM JUL 2016 21P-4706b

7. DATE

DEPENDENT (S) SUPPORT FIDUCIARY FEE IF APPROVED BY VA

SUPERSEDES VA FORM 21-4706b, OCT 2012, WHICH WILL NOT BE USED.

FROM TO

AMOUNT RECEIVED FROM SOCIAL SECURITY

MONTHLY AMT.

INTEREST EARNED ON DEPOSITS

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

NO. OF MONTHS

AMOUNT RECEIVED FROM VA C

(Continued on Reverse)

OMB Control No. 2900-0017 Respondent Burden: 27 Minutes Expiration Date: 07/31/2019

VA FIDUCIARY'S ACCOUNT

NAME OF VETERAN (First-Middle-Last) NAME OF BENEFICIARY (If not veteran)

SECTION I - STATEMENT OF ACCOUNT INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Hub. Show monthly amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the entire accounting period to support the transactions noted on this accounting. IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.

VA FILE NUMBER

C-

ACCOUNTING PERIOD FROM TO

4. ASSETS AT END OF PERIOD*

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

DESCRIPTION AMOUNT

A $

TOTAL AMOUNT OF CHECKING ACCOUNT(S)

TOTAL AMOUNT OF SAVINGS ACCOUNT(S)

TOTAL AMOUNT OF CERTIFICATE(S) OF DEPOSIT

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

IMPORTANT - The fiduciary must account for all funds received on behalf of the beneficiary as VA fiduciary, representative payee for SSA benefits, or in any other fiduciary capacity. The fiduciary must keep receipts and other documentation of expenses because VA may need to examine them during the audit of this accounting.

2. MONEY SPENT ROOM AND BOARD/RENT

OTHER (Specify)

G H

CLOTHING ENTERTAINMENT PERSONAL USE

L M TOTAL SPENT (ADD LINES 2A THRU 2L)

3. TOTAL FUNDS UNDER MANAGEMENT AT END OF PERIOD (SUBTRACT 2M FROM 1I)

* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-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. 8. SUBMITTED BY (Signature and title of fiduciary)

(1) WERE ADDITIONAL BONDS PURCHASED DURING THIS ACCOUNTING PERIOD?

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

E OTHER (List outstanding checks or other issues that impact the total assets.)

5. TOTAL ASSETS (MUST EQUAL ITEM 3)

6. REMARKS (If needed you may attach additional sheets and key responses to item numbers.)

ITEM

MONTHLY AMT.

NO. OF MONTHS

NO. OF MONTHS MONTHLY AMT.

MONTHLY AMT.

MONTHLY AMT.NO. OF MONTHS

NO. OF MONTHS

MONTHLY AMT.

YES NO

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 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.

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. 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.

SIGNATURE OF FIDUCIARY 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.

SERIAL NUMBER DATE OF

PURCHASE

LINE NO.

PURCHASE PRICE

SERIAL NUMBER DATE OF

PURCHASE PURCHASE

PRICE

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, JUL 2016

www.reginfo.gov/public/do/PRAMain

NAME AND ADDRESS OF FIDUCIARY

VA FIDUCIARY HUB

DESCRIPTION

AMOUNT

ITEM

1. MONEY RECEIVED

TOTAL ESTATE AT BEGINNING OF PERIOD

VA FORM

JUL 2016

21P-4706b

7. DATE

DEPENDENT(S) SUPPORT

FIDUCIARY FEE IF APPROVED BY VA

SUPERSEDES VA FORM 21-4706b, OCT 2012, WHICH WILL NOT BE USED.

FROM

AMOUNT RECEIVED FROM SOCIAL SECURITY

MONTHLY AMT.

INTEREST EARNED ON DEPOSITS

AMOUNT RECEIVED FROM OTHER SOURCES

(List in Items 1E thru 1H)

NO. OF MONTHS

AMOUNT RECEIVED FROM VA

(Continued on Reverse)

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

Expiration Date: 07/31/2019

VA FIDUCIARY'S ACCOUNT

NAME OF VETERAN (First-Middle-Last)

NAME OF BENEFICIARY (If not veteran)

SECTION I - STATEMENT OF ACCOUNT

INSTRUCTIONS: Items 1 through 7 are to be completed by the fiduciary and returned to the VA Fiduciary Hub. Show monthly amount where indicated, in addition to amount for accounting period. Attach detailed monthly financial (bank) statements for the

entire accounting period to support the transactions noted on this accounting.

IMPORTANT - SEE PRIVACY ACT INFORMATION ON REVERSE.

VA FILE NUMBER

C-

ACCOUNTING PERIOD

FROM

4. ASSETS AT END OF PERIOD*

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

DESCRIPTION

AMOUNT

TOTAL AMOUNT OF CHECKING

ACCOUNT(S)

TOTAL AMOUNT OF SAVINGS

ACCOUNT(S)

TOTAL AMOUNT OF

CERTIFICATE(S) OF DEPOSIT

TOTAL PURCHASE PRICE OF

SAVINGS BONDS LISTED ON

REVERSE (Complete reverse for total in this field)

2. MONEY SPENT

ROOM AND BOARD/RENT

OTHER (Specify)

CLOTHING

ENTERTAINMENT

PERSONAL USE

TOTAL SPENT (ADD LINES 2A THRU 2L)

3. TOTAL FUNDS UNDER MANAGEMENT AT END OF PERIOD (SUBTRACT 2M FROM 1I)

* NOTE: Pursuant to my signed Fiduciary Agreement (VA Form 21P-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.

8. SUBMITTED BY (Signature and title of fiduciary)

(1) WERE ADDITIONAL BONDS PURCHASED DURING THIS ACCOUNTING PERIOD?

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

OTHER (List outstanding checks or other issues that impact the total assets.)

5. TOTAL ASSETS (MUST EQUAL ITEM 3)

6. REMARKS (If needed you may attach additional sheets and key responses to item numbers.)

ITEM

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

NO. OF MONTHS

MONTHLY AMT.

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg

Department of Veterans Affairs Logo.

9. BACKGROUND INFORMATION

SIGNATURE OF FIDUCIARY

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.

SERIAL NUMBER

DATE OF PURCHASE

LINE NO.

PURCHASE PRICE

SERIAL NUMBER

DATE OF PURCHASE

PURCHASE PRICE

10.

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.

10. EXPLANATION OF BACKGROUND INFORMATION (If necessary)

VA FORM 21P-4706b, JUL 2016

21P-4706B

V. A. Fiduciary's Account

N.Kessinger

Par Knapp

8/01

NOV 2002

1.0

VBA

FROM. NAME AND ADDRESS OF FIDUCIARY.:
TO V. A. FIDUCIARY HUB.:
NAME OF VETERAN (First-Middle-Last).:
NAME OF BENEFICIARY (If not veteran).:
V. A. FILE NUMBER. C-.:
1. MONEY RECEIVED. A. TOTAL ESTATE AT BEGINNING OF PERIOD. AMOUNT.:
1. MONEY RECEIVED. B. AMOUNT RECEIVED FROM V. A. Number or Months. Line 1 of 2.:
1B. AMOUNT RECEIVED FROM V. A. Monthly Amount. :
1B. AMOUNT RECEIVED FROM V. A. AMOUNT. Line 1 of 2.:
1B. AMOUNT RECEIVED FROM V. A. Number or Months. Line 2 of 2.:
1B. AMOUNT RECEIVED FROM V. A. Monthly Amount. :
1B. AMOUNT RECEIVED FROM V. A. AMOUNT. Line 2 of 2.:
1. MONEY RECEIVED. C. AMOUNT RECEIVED FROM SOCIAL SECURITY. Number or Months. Line 1 of 2.:
1C. AMOUNT RECEIVED FROM SOCIAL SECURITY. Monthly Amount.:
1C. AMOUNT RECEIVED FROM SOCIAL SECURITY. AMOUNT. Line 1 of 2.:
1C. AMOUNT RECEIVED FROM SOCIAL SECURITY. Number or Months. Line 2 of 2.:
1C. AMOUNT RECEIVED FROM SOCIAL SECURITY. Monthly Amount.:
1C. AMOUNT RECEIVED FROM SOCIAL SECURITY. AMOUNT. Line 2 of 2.:
1D. INTEREST EARNED ON DEPOSITS. AMOUNT. :
1E. AMOUNT RECEIVED FROM OTHER SOURCES. (List in Items 1E thru 1H). 1F. Description. Line 1 of 3.:
1F. AMOUNT.:
1G. Description. Line 2 of 3.:
1G. AMOUNT.:
1H. Description. Line 3 of 3.:
1H. AMOUNT.:
1I. TOTAL RECEIVED (ADD LINES 1. A. THRU 1H). AMOUNT.:
2. MONEY SPENT. A. ROOM AND BOARD / RENT. Number of Months.:
2. A. ROOM AND BOARD / RENT. Monthly Amount.:
2. A. ROOM AND BOARD / RENT. AMOUNT.:
2B. CLOTHING. AMOUNT. :
2C. ENTERTAINMENT. AMOUNT.:
2D. PERSONAL USE. Number of Months.:
2D. PERSONAL USE. Monthly Amount.:
2D. PERSONAL USE. AMOUNT.:
2E. DEPENDENT(S) SUPPORT. Number of Months.:
2E. DEPENDENT(S) SUPPORT. Monthly Amount.:
2E. DEPENDENT(S) SUPPORT. AMOUNT.:
2F. FIDUCIARY FEE IF APPROVED BY V. A. AMOUNT.:
2G. OTHER (Specify). Line 1 of 6.:
2G. OTHER. AMOUNT.:
2H. SPECIFY OTHER MONEY SPENT. Line 2 of 6.:
2H. OTHER. AMOUNT.:
2I. SPECIFY OTHER MONEY SPENT. Line 3 of 6.:
2I. OTHER. AMOUNT.:
2J. SPECIFY OTHER MONEY SPENT. Line 4 of 6.:
2J. OTHER. AMOUNT.:
2K. SPECIFY OTHER MONEY SPENT. Line 5 of 6.:
2K. OTHER. AMOUNT.:
2L. SPECIFY OTHER MONEY SPENT. Line 6 of 6.:
2L. OTHER. AMOUNT.:
2M. TOTAL SPENT (ADD LINES 2. A. THRU 2L). AMOUNT.:
3. TOTAL FUNDS UNDER MANAGEMENT AT END OF PERIOD (SUBTRACT 2M FROM 1I). AMOUNT.:
4. ASSETS AT END OF PERIOD. A. TOTAL AMOUNT OF CHECKING ACCOUNT(S). AMOUNT.:
4B. TOTAL AMOUNT OF SAVINGS ACCOUNT(S). AMOUNT.:
4C. TOTAL AMOUNT OF CERTIFICATE(S) OF DEPOSIT. AMOUNT.:
4D. TOTAL PURCHASE PRICE OF SAVINGS BONDS LISTED ON REVERSE (Complete reverse for total in this field). AMOUNT.:
4D. (1) NO.:
4E. OTHER (List outstanding checks or other issues that impact the total assets.):
4E. OTHER. AMOUNT.:
5. TOTAL ASSETS (MUST EQUAL ITEM 3). AMOUNT.:
4D. NO.:
6. REMARKS (If needed you may attach additional sheets and key responses to item numbers.):
10. DATE OF PURCHASE. Enter 2 digit month, 2 digit day and 4 digit year.:
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.:
1. SERIAL NUMBER. :
1. PURCHASE PRICE.:
2. SERIAL NUMBER.:
2. PURCHASE PRICE.:
3. SERIAL NUMBER.:
3. PURCHASE PRICE.:
4. SERIAL NUMBER.:
4. PURCHASE PRICE.:
5. SERIAL NUMBER.:
5. PURCHASE PRICE.:
6. SERIAL NUMBER.:
6. PURCHASE PRICE.:
7. SERIAL NUMBER.:
7. PURCHASE PRICE.:
8. SERIAL NUMBER.:
8. PURCHASE PRICE.:
9. SERIAL NUMBER.:
9. PURCHASE PRICE.:
10. SERIAL NUMBER.:
10. PURCHASE PRICE.:
10. EXPLANATION OF BACKGROUND INFORMATION (If necessary).: