Form 21-4703 Fiduciary Agreement

OMB Control No. 2900-0319
Respondent Burden: 5 Minutes

FIDUCIARY AGREEMENT
Privacy Act Notice: VA will not disclose information collected 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 1.576 for routine uses (i.e. request from a 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 mandatory. Giving your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The
VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statue of law in effect
prior to January 1, 1975 and still in effect.
Respondent Burden: We need this information to appoint a fiduciary for the beneficiary’s VA benefits. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 5 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. ADDRESS OF VA OFFICE (Complete mailing address)

2. VA CONTACT/PHONE NUMBER

3. NAME OF VETERAN (First - middle - last)

5. SOCIAL SECURITY NUMBER

4. VA FILE NUMBER

6. NAME(S) OF BENEFICIARY(IES)
A.

D.

B.

E.

C.

F.

7. I, THE UNDERSIGNED FIDUCIARY, HEREBY AGREE TO SERVE AS:
LEGAL CUSTODIAN

CUSTODIAN-IN-FACT

SPOUSE PAYEE
(For veterans only)

INSTITUTIONAL PAYEES
(For veterans only)

and agree to use all beneficiary funds paid by the Department of Veterans Affairs (VA) for the benefit of the beneficiary(ies) listed
above. I agree to invest any surplus funds as shown below in Item 8, or as may later be required by VA.
8A. LUMP SUM AMOUNT

I AGREE TO SAVE THE FOLLOWING AMOUNTS:

8B. MONTHLY AMOUNT

8C. EFFECTIVE DATE

$

$

I agree to release all beneficiary funds, U.S. savings bonds, and other securities under my control as a VA fiduciary upon the
termination of my trust as directed by VA. If a beneficiary is a minor, I will turn over to the beneficiary all of his or her remaining
VA-derived funds, U.S. savings bonds, or other securities at the time the beneficiary reaches the age of majority.
I understand that I
am
am not required to submit periodic accountings to VA of all the beneficiary’s funds I receive and use.
If I am required to account, a VA representative has explained to me the frequency, scope and format of the accounting.
I am aware of the information on the back of this agreement and will comply with the requirements stated.
I understand that this agreement may be altered only with VA approval.
I CERTIFY THAT if and while I am authorized to take a commission, I am not receiving and will not receive any other form of remuneration or
payment in connection with rendering fiduciary services on behalf of the above named beneficiary(ies).
9A. SIGNATURE OF FIDUCIARY

9B. SOCIAL SECURITY OR TAX ID NUMBER
OF FIDUCIARY

9D. NAME OF FIDUCIARY (Type or print)

9E. TITLE OF FIDUCIARY

10A. SIGNATURE OF FIELD EXAMINER

10B. DATE SIGNED

NOTE: This agreement supersedes any existing fiduciary agreement involving the beneficiary(ies).
VA FORM
JUL 2009

21-4703

SUPERSEDES VA FORM 21-4703, MAR 2006,
WHICH WILL NOT BE USED.

9C. DATE SIGNED

BENEFICIARY’S NAME

BENEFICIARY’S FILE NUMBER

FEDERAL FIDUCIARY AGREEMENT
You are being appointed as a Federal Fiduciary for the VA beneficiary listed above. As a Federal Fiduciary, you are
responsible for receiving the beneficiary’s VA income and ensuring the beneficiary’s just debts are paid. Please initial in
the "Initial" column next to each statement of understanding you agree to.
STATEMENT OF UNDERSTANDING

INITIAL

1

I UNDERSTAND THE "INFORMATION FOR FIDUCIARY" ON PAGE 4 OF THIS FORM.

2

I UNDERSTAND THAT FUNDS ARE TO BE USED FOR THE BENEFICIARY AND HIS/HER
RECOGNIZED DEPENDENT, IF APPLICABLE. I UNDERSTAND THAT I CANNOT BORROW, LOAN,
OR GIFT FUNDS BELONGING TO THE BENEFICIARY.
I UNDERSTAND THAT I MUST REPORT ANY OF THE FOLLOWING CHANGES TO THE
FIDUCIARY ACTIVITY IMMEDIATELY:
CHANGE IN ADDRESS OR PHONE NUMBER (BENEFICIARY’S OR FIDUCIARY’S)

3

CHANGE IN INCOME OR DEPENDENTS
INCARCERATION OR HOSPITALIZATION IN A VA OR STATE FACILITY
DEATH OF THE BENEFICIARY OR DEPENDENT OF THE BENEFICIARY

4
5
6
7
8

I UNDERSTAND THAT I MUST ESTABLISH A PROPERLY TITLED BANK ACCOUNT AS FOLLOWS:
BENEFICIARY’S NAME BY YOUR NAME, FEDERAL FIDUCIARY
I UNDERSTAND THAT IN NO INSTANCE SHALL THE BENEFICIARY’S FUNDS BE COMMINGLED
WITH EITHER MY OR ANYONE ELSE’S FUNDS.
I UNDERSTAND THAT ALL DISBURSEMENTS ARE TO BE MADE BY CHECK OR ELECTRONIC
PAYMENT FROM THE CUSTODIAN BANK ACCOUNT. NO CHECKS ARE TO BE WRITTEN FOR
CASH AND NO CASH WITHDRAWALS, NO EXCEPTIONS.
I UNDERSTAND THAT I MUST OBTAIN PRIOR APPROVAL FOR ANY NONRECURRING EXPENSE
OVER $500.00.
I UNDERSTAND THAT I MUST KEEP ACCURATE, COMPLETE RECORDS AND RECEIPTS,
REGARDLESS IF I AM REQUIRED TO SUBMIT PERIODIC ACCOUNTINGS.

9

I UNDERSTAND THAT I AM REQUIRED TO COMPLETE PERIODIC ACCOUNTINGS. THE FIRST
ACCOUNTING IS DUE ON ____________________________.

10

I UNDERSTAND THAT I MUST STRICTLY ADHERE TO THE "FUND USAGE AGREEMENT" ON PAGE 3
OF THIS FORM. ANY DEVIATION MUST BE APPROVED IN WRITING BY THE FIDUCIARY ACTIVITY.

11

I UNDERSTAND THAT I AM/AM NOT REQUIRED TO PROVIDE A SURETY BOND IN THE AMOUNT
OF $ ______________________.

12
13

I UNDERSTAND THAT I WILL BE HELD RESPONSIBLE FOR MISUSE OF THE BENEFICIARY’S
FUNDS OR FOR NOT ADHERING TO THESE REQUIREMENTS.
I UNDERSTAND THAT VA MAY OBTAIN, AT ANY TIME FOR WHICH I AM FIDUCIARY, ASSET
INFORMATION FROM THE FINANCIAL INSTITUTIONS FOR ALL ACCOUNTS ON BEHALF OF
THE BENEFICIARY.

The field examiner has explained my responsibilities and I have received a copy of this form.
SIGNATURE OF FIDUCIARY

DATE SIGNED

SIGNATURE OF FIELD EXAMINER

DATE SIGNED

VA FORM 21-4703, JUL 2009

FUND USAGE AGREEMENT
PART I - MONTHLY INCOME

As a Federal Fiduciary, you are responsible for receiving the beneficiary’s VA income and ensuring the beneficiary’s just
debts are paid. Please complete this section showing the beneficiary’s income.
1
2
3
4
5
6
7
8
9

VA COMPENSATION/PENSION/DIC
VA EDUCATION BENEFIT
SOCIAL SECURITY
OTHER RETIREMENT
WAGES
SPOUSE SOCIAL SECURITY
SPOUSE OTHER INCOME
SPOUSE WAGES
RETROACTIVE BENEFITS

$
$
$
$
$
$
$
$
$

TOTAL

$
PART II - EXPENSES

Please complete this section showing the beneficiary’s expenses.
MONTHLY EXPENSE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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25
26
27
28
29
30
31
32
33
34
35

AUTO INSURANCE
CARE PROVIDERS
CELL PHONE
CLOTHING
CREDIT CARD
CREDIT CARD
CREDIT CARD
DEPENDENT SUPPORT
ELECTRICITY
FIDUCIARY FEE (If approved)
GAS/OIL/FUEL OIL
GROCERIES
INSTITUTIONAL CARE
INSURANCE - HOME/RENTERS
INSURANCE - HEALTH/DENTAL
INSURANCE - LIFE
INTERNET SERVICE
MEDICAL CO-PAYS
MORTGAGE/RENT/ROOM AND BOARD
PERSONAL NEEDS ALLOWANCE
PRESCRIPTIONS
REAL ESTATE TAXES
TELEPHONE
TITHES
TRASH
TV (CABLE, ETC.)
VEHICLE MAINTENANCE (GAS, OIL, ETC.)
VEHICLE PAYMENT
VEHICLE PAYMENT
VEHICLE REGISTRATIONS/TAXES, ETC.
WATER/SEWER
OTHER (Specify)
OTHER (Specify)
OTHER (Specify)
OTHER (Specify)

TOTAL
VA FORM 21-4703, JUL 2009

PAID FROM VA BENEFIT

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$

$

INFORMATION FOR FIDUCIARY
(Note: "Beneficiary" means the veteran or other VA beneficiary(ies))
AUTHORITY. Under authority given by Congress in 38 U.S.C. §5502(a)(1), VA recognizes you as fiduciary (payee) to
receive and manage the VA funds of the beneficiary(ies) named on the front of this agreement. This agreement
supersedes any existing VA fiduciary arrangement involving the beneficiary.
RESTRICTED USE OF VA FUNDS. The VA-derived funds you receive under this agreement are not for your
personal use. You will receive these funds as a federal fiduciary, which means that you use the funds exclusively for the
beneficiary and his or her VA-recognized dependents, if any, and as specifically authorized by VA. You may not mix the
beneficiary’s funds with your own personal funds.
APPROVAL FOR USE OF VA FUNDS. VA must approve any use of a beneficiary’s VA funds. You agree to use
these funds only as specifically authorized by VA. You agree to request VA approval for all spending from these funds,
unless VA has previously authorized the expenditures. Any questions regarding authorized expenditures should be
addressed to the Fiduciary Activity at the address and phone number on the front of this form.
AUTHORIZED INVESTMENTS FOR SURPLUS VA FUNDS. A legal custodian may only place VA funds not
needed by the beneficiary in specific investments. These funds may be placed in U.S. savings bonds or in interest or
dividend-paying accounts in State or Federally insured institutions, whichever is to the beneficiary’s advantage. Excess
funds in a checking account should be placed in a higher earning account; for example, a savings account. Legal
custodians may also use a beneficiary’s surplus VA funds for purchase of a pre-need burial plan or burial insurance on
behalf of the beneficiary.
REGISTRATION OF ACCOUNTS AND INVESTMENTS. Fund accounts must be set up to show proper ownership
as follows: "(Beneficiary’s Name), by (Your Name), Federal fiduciary. Savings bonds must show proper ownership and
existence of the fiduciary relationship, as follows: "(Beneficiary’s Name), (Social Security No.), under custodianship by
designation of the Department of Veterans Affairs." The bonds may not be cashed without VA approval.
ACCOUNTINGS. You must keep complete and accurate records of income received, expenditures, savings and
investments. Information on the front of this agreement shows whether or not you are required by VA to submit periodic
accountings. When accountings are required, you should submit them on the form that VA will give you. Although you
may not be required now to submit accountings, VA may require accountings later. If so, VA will inform you.
CERTIFICATES OF BALANCE ON DEPOSIT AND VERIFICATION. When accountings are required and there
are beneficiary funds on deposit, you must also submit a VA Form 21-4718a, Certificate of Balance on Deposit and
Authorization to Disclose Financial Records. VA will give you that form which also includes an authorization for you to
allow VA to verify deposits directly with the financial institution, if necessary.
BOND AND WITHDRAWAL AGREEMENTS. VA will tell you if you must purchase a corporate surety bond to
protect the beneficiary’s funds or sign a withdrawal agreement to provide additional protection of the beneficiary’s VA
funds.
COMMISSIONS/FEES. You may not take commissions or fees from the beneficiary’s VA funds for your fiduciary
services unless specifically authorized by VA.
TAX EXEMPTION AND CLAIMS OF CREDITORS. By Federal law, a beneficiary’s VA income may not be taxed.
As fiduciary, you must protect the beneficiary’s funds from the claims of creditors. A creditor may not legally take the
beneficiary’s funds from you. Any questions regarding these issues should be addressed to the VA office shown on the
front of this agreement.
NOTIFICATION OF CHANGES. You must inform VA when the beneficiary leaves your custody or has a change of
address. You must also inform VA of any change in the beneficiary’s status that may affect entitlement. Examples are
hospitalization, employment, imprisonment, marriage, separation, divorce, gain or loss of dependents, and death.
PROTECTION OF THE BENEFICIARY. VA will take any necessary action to protect the interest of the beneficiary
including, but not limited to, removing you as payee. VA may take legal action to recover funds from you that have been
misused.
QUESTIONS. When you have questions about your responsibilities as payee, please contact the VA office shown on
the front of this agreement.

VA FORM 21-4703, JUL 2009