27-0820d Report of Non-Receipt of Payment

OMB Control No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

REPORT OF NON-RECEIPT OF PAYMENT
NOTE - This form must be filled out in ink or on a typewriter or
computer, as it becomes a permanent record in the veteran's folder.

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

1. VA OFFICE

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY

EVENING

6B. E-MAIL ADDRESS (If applicable)
7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT (Check)

9. ADDRESS OF PERSON CONTACTED

10. TELEPHONE NUMBER OF PERSON CONTACTED

PERSONAL

TELEPHONE

(Include Area Code)

I certify that I properly identified my caller using the ID Protocol.
11. BRIEF STATEMENT OF INFORMATION GIVEN AND RECEIVED
Beneficiary is requesting tracer action based on the following information:
AMOUNT OF PAYMENT $

DATE OF MISSING PAYMENT(S)
PAYMENT WAS ISSUED VIA :

BDN

VETSNET

PAYMENT METHOD:

PAPER CHECK(S)

TYPE OF PAYMENT:

REGULAR

DIRECT DEPOSIT
RETRO

IRREGULAR

WAS CHECK LOST AND/OR ENDORSED?

YES

NO

N/A

WAS CHECK STOLEN AND/OR ENDORSED?

YES

NO

N/A

WAS ADDRESS CHANGED THIS DATE?

YES

NO

12. CERTIFICATION

I certify that I read the following statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA benefits. The primary
purpose for gathering this information or statement is to make an eligibility determination. It is subject to verification through computer matching programs with
other agencies."
"If the original check is found or received, you must return the original check to the Treasury Department and await receipt of the replacement check. If both checks
are negotiated, then you will be responsible for the duplicate payment. You will receive a letter from the Debt Management Center with instructions concerning
collection."
cc: POA (If applicable)
DIVISION OR SECTION

EXECUTED BY (Signature and title)

TO BE COMPLETED BY FINANCE ONLY
RUPD INPUT DATE

REGIONAL OFFICE

DIVISION OR SECTION

EXECUTED BY (Signature and title)

SIGNATURE

PRIVACY ACT NOTICE: The VA will not disclose information collected on this 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., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to obtain evidence in support of your claim for benefits (38 U.S.C. 501(a) and (b)). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 5 minutes to respond to the questions on this form. VA cannot conduct or sponsor a collection of information unless a valid OMB
number is 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.
VA FORM
APR 2013

27-0820d