Form 29-586 Certification of Change for Correction of Name - Governm

OMB Control No. 2900-0679
Respondent Burden: 10 minutes
Expiration Date: XX/XX/20XX

CERTIFICATION OF CHANGE OR CORRECTION OF NAME
GOVERNMENT LIFE INSURANCE
NOTICE: We have received a communication that indicates your name as it appears on our insurance records should be changed.
If it is different than that shown below, please complete and return this form.
1. NAME AND ADDRESS OF INSURED

2. INSURANCE FILE NUMBER
3. SOCIAL SECURITY NUMBER

PART I - TO BE COMPLETED BY INSURED
4. CHANGE OR CORRECT MY NAME (Type or print)

5. ADDRESS (Complete only if your address is different than that

shown in Item 1)

6. REASON FOR CHANGE OR CORRECTION OF NAME
MARRIAGE

CORRECTION

DIVORCE OR ANNULMENT

OTHER (Specify)

I CERTIFY that I am the insured named in the policy/policies, under the above file number.
7. SIGNATURE OF INSURED (Sign in ink)

8. DATE

PART II - TO BE COMPLETED BY WITNESSES
(To be completed only if change of name is other than marriage, divorce, annulment, or for correction of name.
Two witnesses are required.)
I CERTIFY that I have personally known this insured and know him/her to be one and the same person; that to the best of my
knowledge and belief the change or correction of name is requested for the reason specified.
SIGNATURE OF WITNESS
(Sign in ink)
(A)

ADDRESS OF WITNESS
(B)

DATE
(C)

PENALTY: The law provides that whoever makes any statement of a material fact, knowing it to be false, shall be punished by a fine
or imprisonment, or both.
IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, CALL US TOLL FREE AT 1-800-669-8477.
PRIVACY ACT INFORMATION: 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 - VA, published in the Federal Register. Completion of this form is required to retain benefits. The responses you submit
are considered confidential (38 U.S.C. 5710).
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0679, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB
Control No. 2900-0679 in any correspondence. Do not send your completed VA Form 29-586 to this email address.
VA FORM
XXX 20XX

29-586

SUPERSEDES VA FORM 29-586, APR 2022,
WHICH WILL NOT BE USED.