Form 21P-792 Fiduciary Statement in Support of Appointment

OMB Control No. 2900-0670
Respondent Burden: 15 minutes
Expiration Date: XXXXXXXX

FIDUCIARY STATEMENT IN SUPPORT OF APPOINTMENT
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 38, 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. Giving us your SSN account information or Tax ID number is voluntary. 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 Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is
considered relevant and necessary in order to appoint the appropriate fiduciary for a VA beneficiary. 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 assess your qualification as a potential fiduciary (38 U.S.C. Chapters 55 and 61). Title 38, United States
Code, allows us to ask for this information, and complete this form. We estimate that you will need an average of 15 minutes to review the instructions, find the
information, and complete the 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.
INSTRUCTIONS: All items are to be completed by the prospective fiduciary. Print all answers clearly. Your answer to every question is important to help us assess
your qualification as a potential fiduciary. If you do not know the answer, write "unknown." If you don't have complete identifying information for the beneficiary, VA
will supply that information. For additional space, attach a separate sheet, indicating the item number to which the answers apply. Prospective fiduciaries must complete
this form before certification.

FIDUCIARY IDENTIFICATION

1. NAME

2. ADDRESS

4. E-MAIL ADDRESS (If applicable)

3. TELEPHONE NUMBER
A. DAYTIME (Include Area Code)
5. SOCIAL SECURITY OR TAX ID NUMBER

B. EVENING (Include Area Code)
6. DATE OF BIRTH

BENEFICIARY IDENTIFICATION

7. NAME

8. ADDRESS

10. E-MAIL ADDRESS (If applicable)

9. TELEPHONE NUMBER
A. DAYTIME (Include Area Code)

B. EVENING (Include Area Code)

11. VA CLAIM NUMBER

12. SOCIAL SECURITY NUMBER

13. DATE OF BIRTH

14. TYPE OF VA BENEFIT(S)
COMPENSATION

PENSION

DEPENDENCY AND INDEMNITY COMPENSATION

OTHER (Specify)

FIDUCIARY QUALIFICATIONS

15A. WHAT IS YOUR RELATIONSHIP TO THE BENEFICIARY?

15B. HOW LONG HAVE YOU BEEN ACQUAINTED WITH BENEFICIARY?

16. YOUR HIGHEST EDUCATION LEVEL OR PROFESSIONAL DESIGNATION (college graduate, attorney, etc.)
17A. LIST YOUR SOURCES OF INCOME (wages, retirement pension, disability, etc.)

17B. WHAT IS YOUR APPROXIMATE ANNUAL INCOME?
$

18. LIST THE NAMES, ADDRESSES, AND DAYTIME TELEPHONE NUMBERS OF TWO CHARACTER WITNESSES, UNRELATED TO YOU, WHO
CAN VOUCH FOR YOUR GOOD CHARACTER AND REPUTATION IN THE COMMUNITY. VA MAY CONTACT THESE CHARACTER WITNESSES.
A. NAME

B. NAME

C. ADDRESS

D. ADDRESS

E. DAYTIME PHONE NUMBER (Include Area Code)

F. DAYTIME PHONE NUMBER (Include Area Code)

VA FORM
XXXX

21P-0792

SUPERSEDES VA FORM 21-0792, MAR 2015,
WHICH WILL NOT BE USED.

19. REMARKS

FIDUCIARY BACKGROUND INFORMATION
I understand that the Department of Veterans Affairs may obtain a credit report on me that has been issued within one year of the date
of this application.
Please initial the block
I have NEVER been convicted of an offense under Federal or State law, which resulted in imprisonment for more than one year. I
understand that the Department of Veterans Affairs may obtain criminal background history on me prior to my appointment as
fiduciary.
Please initial the block
I have been convicted of an offense under Federal or State law, which resulted in imprisonment for more than one year. Additionally,
I understand that the Department of Veterans Affairs my obtain criminal background history on me prior to my appointment as
fiduciary.
Please initial the block
I understand that completion of this form will not necessarily result in my appointment as a VA fiduciary.
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

Signature (Do NOT print your name)

Date Signed

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.

VA FORM 21P-0792, XXXX