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

OMB Approved No. 2900-0060
Respondent Burden: 6 Minutes
Expiration Date: XXXXXXXXXX

CLAIM FOR ONE SUM PAYMENT
1. INSURANCE FILE NUMBER

GOVERNMENT LIFE INSURANCE

2. INSURANCE POLICY NUMBER

3. FIRST, MIDDLE, LAST NAME OF INSURED VETERAN

4. 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 8A. If you are signing as the guardian or attorney-in-fact, please include a copy of the court appointment
or power of attorney.
MAIL:
FAX:
This completed form may be submitted by: VA Insurance Center
1-888-748-5822
P.O. Box 7208
Philadelphia, PA 19101
5. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY (Please print)

6. RELATIONSHIP TO INSURED

7. DATE OF BIRTH OF BENEFICIARY

8A. MAILING ADDRESS (MUST BE COMPLETED)

8B. BENEFICIARY'S SOCIAL SECURITY NUMBER

8C. EMAIL ADDRESS

8D. DAYTIME TELEPHONE NUMBER

CERTIFICATION: I certify that the above entries are true and correct to the best of my knowledge and belief.
9. SIGNATURE OF BENEFICIARY, FIDUCIARY OR GUARDIAN (Sign in ink)

10. DATE

COMPLETE THE BANK ACCOUNT INFORMATION BELOW IN BLOCKS A THROUGH E TO RECEIVE THIS PAYMENT
ELECTRONICALLY. THE ACCOUNT MUST BE IN THE NAME OF THE PERSON, ESTATE, OR TRUST DESIGNATED AS
BENEFICIARY OR FIDUCIARY. IF THE BENEFICIARY IS A TRUST OR ESTATE, YOU MUST COMPLETE BOX 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, 36VA29, Veterans and Uniformed Services Personnel Programs
of 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.
Comments on the accuracy of this burden or suggestions to decrease the burden may be included with the submission of this form or sent separately to VA Insurance
Center, P.O. Box 7208, Philadelphia, PA 19101 or faxed to 1-888-748-5822.
VA FORM
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29-4125

SUPERSEDES VA FORM 29-4125, DEC 2016,
WHICH WILL NOT BE USED.