Form VA Form 29-4125 VA Form 29-4125 Claim for One Sum Payment (Government Life Insurance)

OMB Approved No. 2900-0060
Respondent Burden: 6 Minutes
Expiration Date: XX/XX/XXXX

1. INSURANCE FILE NUMBER

CLAIM FOR ONE SUM PAYMENT

2. INSURANCE POLICY NUMBER

GOVERNMENT LIFE INSURANCE

4. FIRST, MIDDLE, LAST NAME OF INSURED VETERAN

3. NET AMOUNT OF INSURANCE
6. BENEFICIARY'S SHARE (Fraction)

5. DATE OF DEATH

INSTRUCTIONS

WE NEED A PHOTOCOPY OF THE VETERAN'S DEATH CERTIFICATE OR A STATEMENT FROM THE ATTENDING
PHYSICIAN SHOWING DATE AND CAUSE OF DEATH. ONLY ONE CERTIFICATE OR STATEMENT IS REQUIRED FOR
OUR RECORDS.
If the beneficiary is a minor or incompetent, the person having custody of the beneficiary should complete the form and give
his/her address in Item 10. If you are signing as the guardian or attorney-in-fact, please include a copy of the court appointment
or power of attorney.
MAIL:

This completed form may be submitted by: VA Insurance Center

P.O. Box 7208
Philadelphia, PA 19101

7. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY (Please print)

FAX:
1-888-748-5822

EMAIL:
[email protected]
NOTE: Only a scanned, signed form will be
accepted, as a valid signature is still required.

8. RELATIONSHIP TO INSURED

9. DATE OF BIRTH OF BENEFICIARY

10A. MAILING ADDRESS (MUST BE COMPLETED)

10B. BENEFICIARY'S SOCIAL SECURITY NUMBER

10C. EMAIL ADDRESS

10D. DAYTIME TELEPHONE NUMBER

CERTIFICATION: I certify that the above entries are true and correct to the best of my knowledge and belief.
11. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN

12. DATE

U.S. TREASURY MANDATES YOU MUST RECEIVE THIS PAYMENT ELECTRONICALLY. ATTACH A VOIDED CHECK OR
COMPLETE BLOCKS A THRU E. THE ACCOUNT MUST BE IN THE NAME OF THE BENEFICIARY. ITEM F MUST BE
COMPLETED. IF THE BENEFICIARY IS A TRUST, ESTATE, OR REPRESENTED BY A FIDUCIARY, YOU MUST SEND A VOIDED
CHECK FOR THAT SPECIFIC ACCOUNT AND COMPLETE ITEM G.
B. ROUTING TRANSIT NUMBER (NINE DIGIT FIELD)

A. NAME OF FINANCIAL INSTITUTION
C. TELEPHONE NUMBER OF FINANCIAL INSTITUTION

D. TYPE
CHECKING

F. BENEFICIARY'S SOCIAL SECURITY NUMBER (Required for Direct Deposit)

E. DEPOSITOR ACCOUNT NUMBER
SAVINGS
G. EIN OR TIN NUMBER (FOR TRUST OR ESTATE ONLY)

Privacy Act Notice: 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 38, Code of Federal
Regulations 1.576 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the
Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN account information is voluntary.
Refusal to provide your SSN by itself will not result in the denial of benefits. 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 Statute of law in effect prior to January 1, 1975, and still in effect.
Respondent Burden: We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 5902). Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 6 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.

IF YOU HAVE QUESTIONS ABOUT THIS FORM, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477
VA FORM
XXX XXXX

29-4125

SUPERSEDES VA FORM 29-4125, MAR 2013,
WHICH WILL NOT BE USED.

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IMPORTANT NOTIFICATION

This is to inform you that the Treasury will only send payments by Direct Deposit (which your bank may refer to as Electronic Funds
Transfer or (EFT).
This means that if you send us an Insurance application that requires us to send you money (For example: loans, cash surrenders,
dividend withdrawals or claims for death benefits), you will have to provide us with your banking information. This is a mandatory
requirement of the Treasury Department.
In order to set up Direct Deposit or EFT you must send us the following information:
(1) If you will be using your checking account, send us:
• A copy of a voided check (Your name must be on the account)
• For identification purposes, please write the Insurance File Number on the voided check
or any other information sent to us.
(2) If you will be using a savings account, send us:
• Your bank's name and address
• Your bank's routing and transit number
• Your bank account number
NOTE: The VA Insurance Center is aware that this may be an inconvenience but this information is mandatory based on
U.S. Treasury regulations and all government agencies must comply. Thank you for your cooperation.

VA FORM 29-4125, XXX XXXX

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