![](media/image1.png)

**May 11, 2006**

#### Filing Record -- Changes to Fiduciary Forms Program Guide

+------------+---------------------------------------------------------+
| #          | > The following chart is intended to provide you with a |
| #### a. In | > record of receipt and filing of changes to the        |
| structions | > Fiduciary Forms Program Guide. Make appropriate       |
|            | > entries as changes are received and filed.            |
+------------+---------------------------------------------------------+

+----------------------+-----------+------------------+---------------+
| Change number ...    | Dated ... | Was filed by ... | On (date) ... |
+----------------------+-----------+------------------+---------------+
| 1.                   |           |                  |               |
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####  {#section .unnumbered}

#### 1. Overview

+------------+---------------------------------------------------------+
| #          | > This publication contains information on the forms    |
| #### a. In | > most frequently utilized to administer the Fiduciary  |
| troduction | > Program. Also included is VA Pamphlet 21-05-1.        |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Although fiduciary personnel do not *complete* some of the forms    |
| > covered, it is essential that they develop knowledge of the forms.  |
| > This includes when the forms should be used and what information is |
| > required on the completed document to make it acceptable.           |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b    | This Program Guide contains detailed instructions for   |
| . Contents | use and completion of the following:                    |
+------------+---------------------------------------------------------+

+----------------------------------------------------------+-----------+
| Topic                                                    | See Page  |
+----------------------------------------------------------+-----------+
| 1.  Overview                                             | 1         |
+----------------------------------------------------------+-----------+
| 2.  VA Form 21-0509: Notice of Fiduciary Commission      | 3         |
+----------------------------------------------------------+-----------+
| 3.  VA Form 21-0520: Certificate of Commissions Approval | 4         |
+----------------------------------------------------------+-----------+
| 4.  VA Form 21-555a: Designation of Payee                | 6         |
+----------------------------------------------------------+-----------+
| 5.  VA Form 21-555: Certificate of Legal Capacity to     | 11        |
|     Receive and Disburse Benefits                        |           |
+----------------------------------------------------------+-----------+
| 6.  VA Form 21-592: Request for Appointment of a         | 15        |
|     Fiduciary, Custodian or Guardian                     |           |
+----------------------------------------------------------+-----------+
| 7.  VA Form 21-0792: Fiduciary Statement in Support of   | 20        |
|     Appointment                                          |           |
+----------------------------------------------------------+-----------+
| 8.  VA Form 21-3045: Estate Action Record                | 24        |
+----------------------------------------------------------+-----------+
| 9.  VA Form 21-3190: Minor Beneficiary Field Examination | 27        |
|     Request and Report                                   |           |
+----------------------------------------------------------+-----------+
| 10. VA Form 21-3537a: Field Examination Request          | 44        |
+----------------------------------------------------------+-----------+
| 11. VA Form 21-3537b: Field Examination Report           | 46        |
+----------------------------------------------------------+-----------+
| 12. VA Form 21-4703: Fiduciary Agreement                 | 51        |
+----------------------------------------------------------+-----------+
| 13. VA Form 21-4706: Court Appointed Fiduciary's         | 55        |
|     Accounting                                           |           |
+----------------------------------------------------------+-----------+
| 14. VA Form 21-4706b: Federal Fiduciary Account          | 57        |
+----------------------------------------------------------+-----------+

Continued on next page

1\. Overview, Continued

  -----------------------------------------------------------------------
  b\. Contents (continued)

  -----------------------------------------------------------------------

  ---------------------------------------------------------- ------------
  Topic                                                      See Page

  15\. VA Form 21-4706c: Court Appointed Fiduciary's         64
  Accounting                                                 

  16\. VA Form 21-4707: Estate Summary                       66

  17\. VA Form 21-4709: Certificate as to Assets             74

  18\. VA Form 21-4716a: Adult Beneficiary Field Examination 77
  Request and Report                                         

  19\. VA Form 21-4718: Account Book                         94

  20\. VA Form 21-4718a: Certificate of Balance on Deposit   96
  and Authorization to Disclose Financial Records            

  21\. VA Form 21-8473: Withdrawal Agreement                 100

  22\. VA Pamphlet 21-05-1: Federal Fiduciary Program Pocket 102
  Folder                                                     
  ---------------------------------------------------------- ------------

+------------+---------------------------------------------------------+
| ##         | > You will find the following acronyms throughout this  |
| ### c. Acr | > guide:                                                |
| onyms Used |                                                         |
+------------+---------------------------------------------------------+

  ------------------- ---------------------------------------------------
  The following ...   Refers to ...

  F&FE                Fiduciary & Field Examination

  FBS                 Fiduciary Beneficiary System

  FE                  Field Examiner

  LIE                 Legal Instruments Examiner

  PGF                 Principal Guardianship Folder

  VSCM                Veterans Service Center Manager

  VSR                 Veteran Service Representative
  ------------------- ---------------------------------------------------

+------------+---------------------------------------------------------+
| ##### d.   | > This Program Guide rescinds M21-1MR, Part XI,         |
| Rescission | > Appendices A through E.                               |
+------------+---------------------------------------------------------+

####  

#### 2. VA Form 21-0509: Notice of Fiduciary Commission 

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-0509 to notify the beneficiary of VA's |
| a. What is | > statutory authority to authorize a fiduciary,         |
|  this form | > appointed by VA, to charge a commission from the      |
|  used for? | > beneficiary's VA benefit for fiduciary services.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | The field examiner must provide VA Form 21-0509 to the  |
| #### b. Wh | incompetent beneficiary when s/he determines that a     |
| en must th | commission is necessary to secure the services of a     |
| is form be | qualified fiduciary to manage the beneficiary's VA      |
|  provided? | benefits. The notice may be given to the beneficiary's  |
|            | caregiver if the beneficiary is unable to comprehend    |
|            | the information.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c.   | > There are no fields for completion on this form and a |
| Completion | > copy need not be retained in the PGF. The field       |
|            | > examiner must, however, state whom s/he gave the form |
|            | > to within the narrative portion of the field          |
|            | > examination report.                                   |
+------------+---------------------------------------------------------+

####  

#### 3. VA Form 21-0520: Certificate of Commissions Approval

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-0520 to obtain and document            |
| a. What is | > concurrence of the VSCM when the field examiner       |
|  this form | > recommends a commissioned fiduciary.                  |
|  used for? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | The field examiner prepares VA Form 21-0520 when s/he   |
| ## b. When | recommends approval of a commission in order to secure  |
|  should th | the services of a qualified fiduciary. The field        |
| is form be | examiner must also fully document justification for his |
|  prepared? | or her recommendation in the narrative portion of the   |
|            | field examination report.                               |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > VA Form 21-0520 must be fully executed prior to certification of    |
| > the fiduciary.                                                      |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ----------------------------- --------------- -------------------------------
  Block# and Title              Completed by    Who enters

  **1 -- NAME OF FIDUCIARY**    FE              The fiduciary's full name.

  **2 - VA FILE NUMBER**        FE              The veteran's claim number.

  **3 -- NAME OF BENEFICIARY**  FE              The beneficiary's full name.

  **4 -- PERCENT COMMISSION OF  FE              The negotiated percentage of
  VA BENEFITS PAID**                            commission recommended.

  **5A -- SIGNATURE OF FIELD    FE              His or her signature.
  EXAMINER**                                    

  **5B - DATE**                 FE              The date signed.

  **6 -- VSCM's                 FE              The appropriate check block to
  CONCURRENCE/NON-CONCURRENCE                   indicate concurrence or
  BLOCK**                                       non-concurrence with the FE's
                                                recommendation.

  **7A -- SIGNATURE OF VSCM OR  VSCM            His or her signature.
  DESIGNEE**                                    
  ----------------------------- --------------- -------------------------------

Continued on next page

3\. VA Form 21-0520: Certificate of Commissions Approval, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------ --------------- -------------------------------
  Block# and Title         Completed by    Who enters

  **7B - DATE**            VSCM            The date signed.

  **8 - REMARKS**          VSCM            Any comments s/he has regarding
                                           the decision to allow or
                                           disallow the recommended
                                           commission.
  ------------------------ --------------- -------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. The "Remarks" field  |
| > must be completed as applicable.                                    |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > Back-file the original, fully executed form on the    |
|  Filing in | > inner left flap of the PGF for so long as the         |
| structions | > fiduciary serves with a commission authorization in   |
|            | > force.                                                |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > If the commission is later discontinued, or a successor fiduciary   |
| > is recognized, file the VA Form 21-0520 down and retain it for the  |
| > life of the PGF.                                                    |
+-----------------------------------------------------------------------+

#### 4. VA Form 21-555a: Designation of Payee

+------------+---------------------------------------------------------+
| #####      | > If you are a field examiner, use VA Form 21-555a to   |
| a. What is | > communicate your processing instructions when you     |
|  this form | > recommend a fiduciary or an SDP beneficiary be        |
|  used for? | > certified. Information must be accurate as it is used |
|            | > to prepare the VA Form 21-555, Certificate of Legal   |
|            | > Capacity to Receive and Disburse Benefits.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Prepare VA Form 21-555a with each initial appointment |
| ## b. When | > field examination, to include successor appointments. |
|  should th | > Submit this form with the completed report of field   |
| is form be | > examination.                                          |
|  prepared? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Your properly completed VA Form 21-555a                             |
|                                                                       |
| -   provides all information necessary to certify a fiduciary, and    |
|                                                                       |
| -   enables a fiduciary to be certified *in emergent cases*, by       |
|     processing the VA Form 21-555, prior to typing of the field       |
|     examination report.                                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > At local option, you may complete VA Form 21-555 in lieu of VA Form |
| > 21-555a. When you recommend a fiduciary appointment, however, you   |
| > may ***not*** date and sign this form.                              |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > As the individual certifying the fiduciary, you must  |
| ### c. Com | > complete this form in its entirety. This form is      |
| pletion in | > generally handwritten. Take care to ensure all        |
| structions | > entries are legible. Refer to the following table for |
|            | > line-by-line completion instructions:                 |
+------------+---------------------------------------------------------+

+-----------------------------+----------------------------------------+
| Block# and Title            | Enter ...                              |
+-----------------------------+----------------------------------------+
| A.  **VA FILE NUMBER**      | the last three digits of the veteran's |
|                             | VA File number.                        |
+-----------------------------+----------------------------------------+
| B.  **LAST NAME OF          | Self-explanatory                       |
|     VETERAN**               |                                        |
+-----------------------------+----------------------------------------+
| C.  **NAME AND ADDRESS OF   | the fiduciary's full name and mailing  |
|     PAYEE**                 | address as it should appear in payment |
|                             | records. This information must be      |
|                             | accurate and legible, as it will be    |
|                             | used for award input.                  |
+-----------------------------+----------------------------------------+

Continued on next page

4\. VA Form 21-555a: Designation of Payee, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Enter ...                              |
+-----------------------------+----------------------------------------+
| A.  **CONTROL ACTION**      | instructions as to when the payee      |
|                             | should be certified, by checking the   |
|                             | appropriate block.                     |
+-----------------------------+----------------------------------------+
| ***CERTIFY***               | a check in this block when VA Form     |
|                             | 21-555 is to be prepared immediately   |
|                             | upon receipt of the field examination  |
|                             | report from the FE.                    |
+-----------------------------+----------------------------------------+
| ***CERTIFY WHEN COURT       | A check in this block when the court   |
| PAPERS RECEIVED***          | papers are not attached to the field   |
|                             | examination report and office          |
|                             | personnel are to prepare VA Form       |
|                             | 21-555 after receipt of court papers.  |
+-----------------------------+----------------------------------------+
| ***REFER TO ESTATE          | a check in this block when the case is |
| ANALYST***                  | to be referred to the LIE for action.  |
|                             | Action will be explained in            |
|                             | "Comments." If VA Form 21-555 is used, |
|                             | put this information in the "Remarks"  |
|                             | or "Other Action Required" section of  |
|                             | the field examination report.          |
+-----------------------------+----------------------------------------+
| ***CERTIFY WHEN REPORT      | a check in this block to delay         |
| TYPED***                    | certification until the field          |
|                             | examination report is complete.        |
+-----------------------------+----------------------------------------+
| ***SEE COMMENTS***          | a check in this block to alert office  |
|                             | personnel to review "Comments" for     |
|                             | additional action items or explanatory |
|                             | remarks. This block can be used to     |
|                             | request that additional information be |
|                             | entered on VA Form 21-555. If VAF      |
|                             | 21-555 is used, place this information |
|                             | in "Remarks."                          |
+-----------------------------+----------------------------------------+
| B.  **PAYEE IS**            | a check in the appropriate block to    |
|                             | designate the mode of payment          |
|                             | selected.                              |
+-----------------------------+----------------------------------------+

Continued on next page

4\. VA Form 21-555a: Designation of Payee, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+---+----------------------------------------+
| Block# and Title            | E |                                        |
|                             | n |                                        |
|                             | t |                                        |
|                             | e |                                        |
|                             | r |                                        |
|                             | . |                                        |
|                             | . |                                        |
|                             | . |                                        |
+-----------------------------+---+----------------------------------------+
| C.  **NAME OF               |   | the names of any beneficiary *not*     |
|     BENEFICIARIES**         |   | identified in the award action or on   |
|                             |   | the VA Form 21-592. If VA Form 21-592  |
|                             |   | is incorrect, the FE should list the   |
|                             |   | names of all beneficiaries for whom    |
|                             |   | the certification of this fiduciary    |
|                             |   | applies on VA Form 21-555a (or VA Form |
|                             |   | 21-555).                               |
+-----------------------------+---+----------------------------------------+
| D.  **PAYMENT               | i |                                        |
|     INSTRUCTIONS**          | n |                                        |
|                             | B |                                        |
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|                             | . |                                        |
+-----------------------------+---+----------------------------------------+
| ***DISBURSEMENT OF***       | - |                                        |
|                             |   |                                        |
| ***MONTHLY BENEFITS***      |   |                                        |
|                             |   |                                        |
|                             | a |                                        |
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|                             | a |                                        |
|                             | m |                                        |
|                             | o |                                        |
|                             | u |                                        |
|                             | n |                                        |
|                             | t |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | a |                                        |
|                             | n |                                        |
|                             | d |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | e |                                        |
|                             | f |                                        |
|                             | f |                                        |
|                             | e |                                        |
|                             | c |                                        |
|                             | t |                                        |
|                             | i |                                        |
|                             | v |                                        |
|                             | e |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | d |                                        |
|                             | a |                                        |
|                             | t |                                        |
|                             | e |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | o |                                        |
|                             | n |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | t |                                        |
|                             | h |                                        |
|                             | e |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | a |                                        |
|                             | p |                                        |
|                             | p |                                        |
|                             | r |                                        |
|                             | o |                                        |
|                             | p |                                        |
|                             | r |                                        |
|                             | i |                                        |
|                             | a |                                        |
|                             | t |                                        |
|                             | e |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             |   |                                        |
|                             | l |                                        |
|                             | i |                                        |
|                             | n |                                        |
|                             | e |                                        |
|                             | s |                                        |
|                             | . |                                        |
+-----------------------------+---+----------------------------------------+

Continued on next page

4\. VA Form 21-555a: Designation of Payee, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Enter ...                              |
+-----------------------------+----------------------------------------+
| E.  **ACCOUNTING            | the accounting due date and check the  |
|     INFORMATION**           | appropriate block(s) for the type of   |
|                             | case. If the accounting is required on |
|                             | other than an annual basis, enter the  |
|                             | accounting interval in "Comments."     |
|                             | Also use "Comments" to refer to        |
|                             | supplemental instructions relating to  |
|                             | local procedures.                      |
|                             |                                        |
|                             | This information is necessary in all   |
|                             | cases that require an accounting. It   |
|                             | lets office personnel know what type   |
|                             | of accounting call letter and          |
|                             | enclosures are to be sent and who will |
|                             | prepare the accounting.                |
|                             |                                        |
|                             | When VA Form 21-555 is used in lieu of |
|                             | VA Form 21-555a, enter the information |
|                             | in the "Remarks" and "Other Action     |
|                             | Required" sections of the field        |
|                             | examination report.                    |
+-----------------------------+----------------------------------------+
| ***VA SERVICE***            | when the VSCM will prepare and either  |
|                             | the VSCM or District Counsel will      |
|                             | present the accounting to the court.   |
|                             | (This situation rarely occurs.)        |
+-----------------------------+----------------------------------------+
| ***FIDUCIARY SERVICE***     | when the fiduciary will prepare and    |
|                             | present the accounting to the court.   |
+-----------------------------+----------------------------------------+
| ***FIDUCIARY                | when the fiduciary will prepare the    |
| PREPARES/FIDUCIARY          | accounting and forward it to the VSCM  |
| PRESENTS***                 | for review. If the accounting is       |
|                             | acceptable and the Regional Counsel    |
|                             | makes the court appearances, the       |
|                             | accounting will be forwarded to the    |
|                             | Regional Counsel for preparation of    |
|                             | petition and order and presentation to |
|                             | the court.                             |
+-----------------------------+----------------------------------------+
| ***LEGAL CUSTODIAN***       | when the fiduciary will prepare the    |
|                             | accounting and submit it to the VSCM.  |
+-----------------------------+----------------------------------------+

Continued on next page

4\. VA Form 21-555a: Designation of Payee, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Enter ...                              |
+-----------------------------+----------------------------------------+
| ***INDIVIDUAL CT. FID.***   | when the fiduciary is an individual    |
|                             | appointed by the court and will        |
|                             | prepare and present the accounting or  |
|                             | have a private attorney prepare and    |
|                             | present it.                            |
+-----------------------------+----------------------------------------+
| ***CORPORATE CT. FID.***    | when the fiduciary is a bank or trust  |
|                             | company, and the company will prepare  |
|                             | and submit the accounting to the VSCM. |
+-----------------------------+----------------------------------------+
| ***INSTITUTIONAL***         | when the fiduciary is the chief        |
|                             | officer of a non-VA institution, and   |
|                             | the fiduciary will submit the          |
|                             | accounting to the VSCM.                |
+-----------------------------+----------------------------------------+
| F.  **SUPPORTING PAPERS**   | a check in the appropriate block to    |
|                             | indicate                               |
|                             |                                        |
|                             | -   whether supporting papers are      |
|                             |     attached or are due at a later     |
|                             |     date. If due at a later date,      |
|                             |     enter the date when the supporting |
|                             |     papers may be expected.            |
|                             |                                        |
|                             | -   what supporting papers are         |
|                             |     attached or expected. If "Other"   |
|                             |     is checked, specify in "Comments"  |
|                             |     what the other papers are. If VA   |
|                             |     Form 21-555 is used, include this  |
|                             |     information in "Remarks."          |
+-----------------------------+----------------------------------------+
| G.  **COMMENTS**            | any special comments, instructions,    |
|                             | etc. that might be necessary to        |
|                             | prepare VA Form 21-555.                |
+-----------------------------+----------------------------------------+
| H.  **SIGNATURE**           | your signature.                        |
+-----------------------------+----------------------------------------+
| I.  **DATE**                | the date you sign the form.            |
+-----------------------------+----------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > File the original document in the PGF with the VA     |
|  Filing In | > Form 21-555. It is generally suggested that these     |
| structions | > documents be filed on the flap containing computer    |
|            | > generated notices and payment actions. Retain it for  |
|            | > the life of the PGF.                                  |
+------------+---------------------------------------------------------+

#### 5. VA Form 21-555: Certificate of Legal Capacity to Receive and Disburse Benefits 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-555 is used to                             |
| a. What is |                                                         |
|  this form | -   designate a fiduciary,                              |
|  used for? |                                                         |
|            | -   specify the mode of payment, and                    |
|            |                                                         |
|            | -   provide instructions for release of VA benefits due |
|            |     an incompetent beneficiary.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Do not prepare VA Form 21-555 until the field         |
| ## b. When | > examiner has completed his or her investigation,      |
|  should th | > concurred with the finding of incompetence, and       |
| is form be | > appointed a fiduciary for the incompetent             |
|  prepared? | > beneficiary.                                          |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > In-house personnel generally prepare this document, which serves as |
| > the official appointment of the fiduciary.                          |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** While the field examiner may prepare the VA Form        |
| > 21-555, the field examiner who certified the payee may ***not***    |
| > sign this document.                                                 |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > An in-house employee, generally the legal instruments |
| ### c. Com | > examiner, completes this form using data from VA Form |
| pletion in | > 21-555a submitted by the field examiner. At local     |
| structions | > option, the field examiner may complete VA Form       |
|            | > 21-555 in lieu of VA Form 21-555a. The field examiner |
|            | > recommending the appointment may ***not***, however,  |
|            | > date and sign this form. Refer to the following table |
|            | > for line-by-line completion instructions:             |
+------------+---------------------------------------------------------+

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **VA FILE NO.**             | the veteran's VA claim number          |
+-----------------------------+----------------------------------------+
| **TO/COPY TO**              | -   identification of the requesting   |
|                             |     VA Regional Office or Insurance    |
|                             |     Center, with copy to               |
|                             |                                        |
|                             | -   any other interested VA element    |
|                             |     holding funds belonging to the     |
|                             |     beneficiary.                       |
+-----------------------------+----------------------------------------+
| **NAME OF VETERAN**         | veteran's full name                    |
+-----------------------------+----------------------------------------+
| **SOCIAL SECURITY NO.**     | veteran's Social Security number       |
+-----------------------------+----------------------------------------+

Continued on next page

5\. VA Form 21-555: Certificate of Legal Capacity to Receive and
Disburse Benefits, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **NAME AND ADDRESS OF       | the payee's name and address.          |
| PAYEE**                     | Information must be accurate, as this  |
|                             | data will be used for award input.     |
+-----------------------------+----------------------------------------+
| **POLICY NO.**              | the policy number for VA insurance (if |
|                             | applicable).                           |
+-----------------------------+----------------------------------------+
| **BENEFICIARY IS:**         | a checkmark to identify the            |
|                             | beneficiary as a "veteran," "minor,"   |
|                             | or "other adult."                      |
+-----------------------------+----------------------------------------+
| **PAYEE DESIGNATION AS:**   | a checkmark in the appropriate block   |
|                             | to identify the mode of payment.       |
+-----------------------------+----------------------------------------+
| **NAME OF BENEFICIARIES     | the names of any beneficiary *other    |
| OTHER THAN VETERAN (1 --    | than the veteran*. Refer to VA Form    |
| 10)**                       | 21-555a. The FE should have entered    |
|                             | the names of all beneficiaries for     |
|                             | whom the certification of this         |
|                             | fiduciary applies.                     |
+-----------------------------+----------------------------------------+
| **NAME AND ADDRESS OF COURT | Self-explanatory.                      |
| OF APPOINTMENT**            |                                        |
|                             | -   Use when the beneficiary is        |
|                             |     incompetent only by Court decree   |
|                             |     and not by VA rating.              |
|                             |                                        |
|                             | -   Enter even if court appointment is |
|                             |     by-passed in favor of a federal    |
|                             |     fiduciary arrangement.             |
+-----------------------------+----------------------------------------+
| **CAUSE NO.**               | the case number assigned by the court  |
|                             | that found the beneficiary             |
|                             | incompetent.                           |
+-----------------------------+----------------------------------------+
| **DATE OF APPOINTMENT**     | the date the court issued letters of   |
|                             | conservatorship, guardianship, etc.    |
+-----------------------------+----------------------------------------+

Continued on next page

5\. VA Form 21-555: Certificate of Legal Capacity to Receive and
Disburse Benefits, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **PAYEE INSTRUCTIONS --**   |                                        |
| The FE specifies            |                                        |
| distribution of monthly     |                                        |
| benefits, and PFOP or       |                                        |
| withheld funds.             |                                        |
+-----------------------------+----------------------------------------+
| ***DISBURSEMENT OF***       | -   a checkmark in the first ("ALL     |
|                             |     MONTHLY") block if all monthly VA  |
| ***MONTHLY BENEFITS***      |     benefits are to be released to the |
|                             |     payee.                             |
|                             |                                        |
|                             | -   a checkmark in the second block if |
|                             |     only part of monthly benefits are  |
|                             |     to be released to the payee.       |
|                             |                                        |
|                             | On the first line, indicate the        |
|                             | monthly amount to be sent to the       |
|                             | payee. Also select the appropriate     |
|                             | block to indicate whether the rest is  |
|                             | to be placed in PFOP or withheld.      |
|                             |                                        |
|                             | Refer to the Fiduciary Program Manual  |
|                             | for instructions on withheld funds and |
|                             | personal funds of patient (PFOP).      |
+-----------------------------+----------------------------------------+
| ***RELEASE OF PFOP OR       | -   a checkmark in the appropriate     |
| WITHHELD FUNDS***           |     block to advise how PFOP funds are |
|                             |     to be released to the payee.       |
|                             |     Options include lump sum PFOP,     |
|                             |     lump withheld funds, and monthly   |
|                             |     PFOP.                              |
|                             |                                        |
|                             | -   the amount and effective date on   |
|                             |     the appropriate lines.             |
+-----------------------------+----------------------------------------+
| **REMARKS**                 | any special payment instructions.      |
+-----------------------------+----------------------------------------+
| **PAYMENT ACTION AUTHORIZED | a checkmark in the appropriate block,  |
| OR RECOMMENDED**            | to specify whether payment will be to  |
|                             |                                        |
|                             | -   a fiduciary,                       |
|                             |                                        |
|                             | -   the beneficiary under VA           |
|                             |     supervision (SDP), or              |
|                             |                                        |
|                             | -   direct to the beneficiary.         |
+-----------------------------+----------------------------------------+

Continued on next page

5\. VA Form 21-555: Certificate of Legal Capacity to Receive and
Disburse Benefits, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **DATE**                       the date the certificate is prepared and
                                 signed.

  **SIGNATURE OF THE FIELD       The signature of the VSCM, or designee.
  FACILITY DIVISION CHIEF**      (The FE who recommended the fiduciary
                                 may ***not*** sign this form.)

  **LOCATION OF OFFICE**         the identification and location of
                                 certifying field office (i.e. VARO,
                                 city, state).
  ------------------------------ ----------------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > Forward the original document to the requesting       |
|  Filing In | > element. File a copy in the PGF with the VA Form      |
| structions | > 21-555a (if used). It is generally suggested that     |
|            | > these documents be filed on the flap containing       |
|            | > computer generated notices and payment records.       |
|            | > Retain it for the life of the PGF.                    |
+------------+---------------------------------------------------------+

#### 6. VA Form 21-592: Request for Appointment of a Fiduciary, Custodian or Guardian 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-592 is used to request appointment of a    |
| a. What is | > fiduciary.                                            |
|  this form |                                                         |
|  used for? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | Prepare VA Form 21-592 to request certification of a    |
| ## b. When | payee when a VA Rating decision, or a court of          |
|  should th | competent jurisdiction, finds a beneficiary             |
| is form be | incompetent.                                            |
|  prepared? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > This form is generally prepared by either a VSR on the Post         |
| > Determination Team within the Veterans Service Center, or           |
| > designated F&FE personnel (generally a Fiduciary VSR). This         |
| > document is the initial step in the fiduciary certification process |
| > and is required for the initial appointment of a fiduciary.         |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > You will find a template for VA Form 21-592 in EPSS.  |
| ### c. Com | > Use this template to ensure your completed document   |
| pletion in | > contains sufficient information to enable the field   |
| structions | > examiner to make an informed fiduciary appointment.   |
|            | > Refer to the following table for line-by-line         |
|            | > completion instructions:                              |
+------------+---------------------------------------------------------+

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **TO**                         the identification (i.e. VARO, VAMROC,
                                 etc.) and location of the Fiduciary
                                 Activity with jurisdiction over the area
                                 where the beneficiary resides.

  **1. FIRST NAME -- MIDDLE      Self-explanatory.
  INITIAL -- LAST NAME OF        
  VETERAN**                      

  **2. VETERAN'S SOCIAL SECURITY Self-explanatory.
  NO.**                          

  **3. FILE NO.**                the veteran's VA file number.

  **4A. PERIOD OF SERVICE**      a checkmark in the appropriate block (or
                                 blocks) to identify the veteran's period
                                 (or periods) of active duty service.

  **4B. SERVICE NO.**            the veteran's military service number.

  **5. TYPE OF BENEFITS**        a checkmark in the appropriate block (or
                                 blocks) to identify the type of VA
                                 benefit payable.
  ------------------------------ ----------------------------------------

Continued on next page

6\. VA Form 21-592: Request for Appointment of a Fiduciary, Custodian or
Guardian, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **6. BENEFITS PAYABLE TO**  | a checkmark in the appropriate block   |
|                             | to identify the beneficiary type (i.e. |
|                             | veteran, widow/widower, etc.).         |
+-----------------------------+----------------------------------------+
| **\[MINOR OR INCOMPETENT    |                                        |
| information\]**             |                                        |
+-----------------------------+----------------------------------------+
| **7. NAME AND ADDRESS**     | the name and physical location of the  |
|                             | beneficiary. The address information   |
|                             | must be a physical address. ***Do      |
|                             | not*** enter P. O. Box locations       |
|                             | unless the physical address is not     |
|                             | available.                             |
+-----------------------------+----------------------------------------+
| **8. DATE OF BIRTH**        | the *beneficiary's* date of birth.     |
+-----------------------------+----------------------------------------+
| **9.**                      | Self-explanatory.                      |
|                             |                                        |
| **IF INSTITUTIONALIZED,     |                                        |
| NAME AND ADDRESS OF         |                                        |
| FACILITY**                  |                                        |
+-----------------------------+----------------------------------------+
| **10. LEGAL RESIDENCE**     | the State and county of the            |
|                             | beneficiary's residence.               |
+-----------------------------+----------------------------------------+
| **11. CLAIMANT'S SOCIAL     | the beneficiary's Social Security      |
| SECURITY NUMBER**           | number, if different from veteran.     |
+-----------------------------+----------------------------------------+
| **12A. SOCIAL SECURITY      | the beneficiary's Social Security      |
| BENEFIT -- MONTHLY          | benefit amount. If not of record in    |
| PAYMENT**                   | the claims file, this information is   |
|                             | available through SHARE. If none,      |
|                             | enter zero.                            |
+-----------------------------+----------------------------------------+
| **12B. SOCIAL SECURITY      | the effective date of the              |
| BENEFIT -- EFFECTIVE DATE** | beneficiary's Social Security benefit, |
|                             | as reflected in SHARE. If none, enter  |
|                             | zero.                                  |
+-----------------------------+----------------------------------------+
| **13A. ANY OTHER SOURCE OF  | a checkmark under "yes" or "no" to     |
| BENEFITS?**                 | indicate if there is other known       |
|                             | income.                                |
+-----------------------------+----------------------------------------+
| **13B. SOURCE**             | the source of other income.            |
+-----------------------------+----------------------------------------+
| **13C. MONTHLY PAYMENT**    | the monthly amount of other income.    |
+-----------------------------+----------------------------------------+
| **13D. EFFECTIVE DATE**     | the effective date of the amount       |
|                             | listed in 13C, if known. If unknown,   |
|                             | enter "unknown."                       |
+-----------------------------+----------------------------------------+

Continued on next page

6\. VA Form 21-592: Request for Appointment of a Fiduciary, Custodian or
Guardian, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **14A. NAME AND ADDRESS OF     Self-explanatory. If none of record,
  SPOUSE, PARENT, NEXT OF KIN,   enter "none of record."
  OR NEXT FRIEND OF MINOR OR     
  INCOMPETENT**                  

  **14B. RELATIONSHIP**          the relationship of the individual
                                 identified in 14A. If unknown, enter
                                 "unknown."

  **14C. TELEPHONE NUMBER**      the telephone number of the individual
                                 identified in 14A. If unknown, enter
                                 "unknown."

  **15A. NAME AND ADDRESS OF     Self-explanatory. If unknown, enter
  PERSON HAVING CUSTODY OF MINOR "unknown."
  OR INCOMPETENT**               

  **15B. RELATIONSHIP**          the relationship of the individual
                                 identified in 15A. If unknown, enter
                                 "unknown."

  **15C. TELEPHONE NUMBER**      the telephone number of the individual
                                 identified in 15A. If unknown, enter
                                 "unknown."

  **\[BENEFITS PAYABLE           
  information\]**                

  **16A. AMOUNT OF BENEFITS      the amount of any retroactive benefits
  ENTITLED TO BUT UNPAID TO      payable through the date the 21-592 is
  DATE**                         prepared.

  **16B. MONTHLY                 the recurrent monthly benefit and
  PAYMENTS/EFFECTIVE DATES**     effective date, where applicable. In
                                 insurance cases, there will generally
                                 not be a monthly amount.

  **17. AMOUNTS IN PFOP, IF      the balance of any funds held in PFOP
  KNOWN, AND AMOUNTS WITHHELD    account, as well as any amount withheld
  UNDER 38 CFR 3.557**           under 38 CFR 3.557, if of record. If
                                 none of record, enter "none of record."
  ------------------------------ ----------------------------------------

Continued on next page

6\. VA Form 21-592: Request for Appointment of a Fiduciary, Custodian or
Guardian, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **18. REMARKS**                any additional information that may be
                                 of value to the FE. Examples include the
                                 basis for any withheld funds, identity
                                 of apportionees, etc. Also use this
                                 block to provide any information to
                                 alert the FE if there is indication the
                                 beneficiary may be dangerous, etc.

  **\[EXAMINATION WHICH WAS THE  
  BASIS FOR RATING OF            
  INCOMPETENCY information\]**   

  **19. NAMES AND LOCATIONS OF   the identity of the physician or
  PHYSICIANS OR HOSPITALS**      hospital that generated medical
                                 information used to rate the beneficiary
                                 incompetent.

  **20. DATE OF EXAMINATION**    the date of the medical examination used
                                 to rate the beneficiary incompetent.

  **21. DIAGNOSIS**              the beneficiary's medical diagnosis,
                                 specifically those that relate to his or
                                 her mental condition.

  **22. DATE OF RATING OF        the date of VA rating of incompetence,
  INCOMPETENCY**                 if applicable.

  **23. NAME AND ADDRESS OF      the identify of the beneficiary's Power
  PERSON, RECOGNIZED ATTORNEY,   of Attorney, or other legal
  SERVICE REPRESENTATIVE OR      representative recognized by VA, if
  COOPERATING AGENCY PROSECUTING applicable.
  CLAIMS OR CORRESPONDING IN     
  BEHALF OF MINOR OR             
  INCOMPETENT**                  

  **24. SIGNATURE OF VETERAN     the signature of the VSCM or designee
  SEVICE CENTER MANAGER**        
  ------------------------------ ----------------------------------------

Continued on next page

6\. VA Form 21-592: Request for Appointment of a Fiduciary, Custodian or
Guardian, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **25. OFFICE AND ADDRESS**     the identify the office generating the
                                 request, along with mailing address.

  **26. DATE**                   the date the VSCM signs the request.
  ------------------------------ ----------------------------------------

+-----------------------------------------------------------------------+
| > ***Notes:***                                                        |
|                                                                       |
| -   Shaded areas represent ***minimum*** required entries. These      |
|     fields require entry in ***all*** cases. Other fields must be     |
|     completed as applicable.                                          |
|                                                                       |
| -   Consider providing these instructions to all individuals that     |
|     routinely complete VA Forms 21-592, to                            |
|                                                                       |
|     \- facilitate acceptable requests, and                            |
|                                                                       |
|     \- eliminate unnecessary action by the field examiner to develop  |
|     for missing                                                       |
|                                                                       |
|     information.                                                      |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > File the original document in the PGF. Retain it for  |
|  Filing In | > the life of the folder.                               |
| structions |                                                         |
+------------+---------------------------------------------------------+

#### 7. VA Form 21-0792: Fiduciary Statement in Support of Appointment

+------+-------------------------------+-------------------------------+
| #### | > VA Form 21-0792 is used for |                               |
| # a. |                               |                               |
|  Wha |                               |                               |
| t is |                               |                               |
|  thi |                               |                               |
| s fo |                               |                               |
| rm u |                               |                               |
| sed  |                               |                               |
| for? |                               |                               |
+------+-------------------------------+-------------------------------+

+------------+---------------------------------------------------------+
| ####       | > VA Form 21-0792 must be completed by any individual   |
| # b. When  | > prospective fiduciary. It is required for both        |
| should thi | > court-appointed and federal fiduciaries and must be   |
| s form be  | > completed even if the individual meets an exception   |
| completed? | > to the credit report requirement.                     |
+------------+---------------------------------------------------------+

[]{.mark}

+-----------------------------------------------------------------------+
| > At local option, the form may be                                    |
|                                                                       |
| -   mailed to the prospective fiduciary for completion prior to the   |
|     personal interview, or                                            |
|                                                                       |
| -   completed at the time of the personal interview.                  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > If the prospective fiduciary is a multi-fiduciary, *a new form is   |
| > required* *for each beneficiary* at the time of certification.      |
| > Photocopies are not acceptable.                                     |
+-----------------------------------------------------------------------+

[]{.mark}

+------------+---------------------------------------------------------+
| ##         | > The prospective fiduciary must complete all entries   |
| ### c. Com | > on VA Form 21-0792, as                                |
| pletion In |                                                         |
| structions | -   as it serves as the basis for the individual's      |
|            |     certification as a VA fiduciary, and                |
|            |                                                         |
|            | -   includes penalties for willful submission of false  |
|            |     evidence.                                           |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > VA may supply identifying information about the beneficiary if      |
| > necessary, however, the fiduciary must make the actual entries.     |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The following table provides instructions for completion.           |
+-----------------------------------------------------------------------+

  ----------------------------- -----------------------------------------
  Section                       Required Information

  **FIDUCIARY IDENTIFICATION**  

  **1. NAME**                   The fiduciary's name exactly as they wish
                                it to appear in VA payment records.

  **2. ADDRESS**                The address the fiduciary wishes VA to
                                use in VA payment records and on
                                correspondence relating to the
                                beneficiary.

  **3. TELEPHONE NUMBER**       

  **A. DAYTIME**                Self-explanatory.

  **B. EVENING**                Self-explanatory.
  ----------------------------- -----------------------------------------

Continued on next page

7\. VA Form 21-0792: Fiduciary Statement in Support of Appointment,
Continued

  -----------------------------------------------------------------------
  c\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+----------------------------+-----------------------------------------+
| Section                    | Required Information                    |
+----------------------------+-----------------------------------------+
| **4. SOCIAL SECURITY OR    | Enter the *prospective fiduciary's*     |
| TAX ID NUMBER**            | Social Security Number.                 |
+----------------------------+-----------------------------------------+
| **5. DATE OF BIRTH**       | Enter the *prospective fiduciary's*     |
|                            | date of birth.                          |
+----------------------------+-----------------------------------------+
| **BENEFICIARY              |                                         |
| IDENTIFICATION**           |                                         |
+----------------------------+-----------------------------------------+
| **6. NAME**                | Self-explanatory.                       |
+----------------------------+-----------------------------------------+
| **7. ADDRESS**             | Self-explanatory.                       |
+----------------------------+-----------------------------------------+
| **8. TELEPHONE NUMBER**    |                                         |
+----------------------------+-----------------------------------------+
| **A. DAYTIME**             | Self-explanatory.                       |
+----------------------------+-----------------------------------------+
| **B. EVENING**             | Self-explanatory.                       |
+----------------------------+-----------------------------------------+
| **9. VA CLAIM NUMBER**     | Self-explanatory.                       |
+----------------------------+-----------------------------------------+
| **10. SOCIAL SECURITY      | Enter the *beneficiary's* Social        |
| NUMBER**                   | Security Number.                        |
+----------------------------+-----------------------------------------+
| **11. DATE OF BIRTH**      | Enter the *beneficiary's* date of       |
|                            | birth.                                  |
+----------------------------+-----------------------------------------+
| **12. TYPE OF VA           | Check the appropriate block to specify  |
| BENEFIT(S)**               | the type of VA benefit payable. Options |
|                            | include:                                |
|                            |                                         |
|                            | -   COMPENSATION                        |
|                            |                                         |
|                            | -   PENSION                             |
|                            |                                         |
|                            | -   DEPENDENCY AND INDEMNITY            |
|                            |     COMPENSATION                        |
|                            |                                         |
|                            | -   OTHER (Specify)                     |
+----------------------------+-----------------------------------------+
| **FIDUCIARY                |                                         |
| QUALIFICATIONS**           |                                         |
+----------------------------+-----------------------------------------+
| **13A. WHAT IS YOUR        | Relationship to the beneficiary (i.e.,  |
| RELATIONSHIP TO THE        | parent, sibling, friend, pastor, etc.). |
| BENEFICIARY?**             |                                         |
|                            | Professional fiduciaries that are not   |
|                            | related to the beneficiary should state |
|                            | "none."                                 |
+----------------------------+-----------------------------------------+
| **13B. HOW LONG HAVE YOU   | Self-explanatory. Professional          |
| BEEN ACQUAINTED WITH       | fiduciaries that are not acquainted     |
| BENEFICIARY?**             | with the beneficiary should state this  |
|                            | fact.                                   |
+----------------------------+-----------------------------------------+
| **14. YOUR HIGHEST         | Enter high school graduate, college,    |
| EDUCATION LEVEL OR         | master's, JD, doctorate, etc.           |
| PROFESSIONAL DESIGNATION** |                                         |
+----------------------------+-----------------------------------------+

Continued on next page

7\. VA Form 21-0792: Fiduciary Statement in Support of Appointment,
Continued

  -----------------------------------------------------------------------
  c\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ----------------------------- -----------------------------------------
  Section                       Required Information

  **15A. LIST YOUR SOURCES OF   Self-explanatory. The fact that an
  INCOME**                      individual has an adequate income and
                                will not have to rely on the
                                beneficiary\'s VA income is an important
                                consideration in qualifying that
                                individual as a VA fiduciary.

  **15B. WHAT IS YOUR           Self-explanatory. See explanation above.
  APPROXIMATE ANNUAL INCOME?**  

  **16. 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.**  

  **16A. and 16B. NAME**        These fields are self-explanatory and
                                must be completed by each individual
                                fiduciary. Although the fiduciary may
                                meet criteria for exemption from this
                                requirement, and we likely will not
                                contact the character witness in those
                                cases, they should provide this
                                information.

  **16C. and 16D. ADDRESS**     

  **16E. and 16F. DAYTIME PHONE 
  NUMBER**                      

  **17. REMARKS**               The prospective fiduciary may enter any
                                information in this block that they feel
                                is pertinent to VA's determination of
                                their suitability to serve. For instance,
                                if the prospective fiduciary currently
                                assists the beneficiary with their funds
                                on an informal basis, or the beneficiary
                                has given them Power-of-Attorney to
                                assist them with fund management, they
                                may feel that their prior history with
                                the beneficiary supports their
                                appointment.
  ----------------------------- -----------------------------------------

Continued on next page

7\. VA Form 21-0792: Fiduciary Statement in Support of Appointment,
Continued

  -----------------------------------------------------------------------
  c\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+----------------------------+-----------------------------------------+
| Section                    | Required Information                    |
+----------------------------+-----------------------------------------+
| **FIDUCIARY BACKGROUND     |                                         |
| INFORMATION**              |                                         |
+----------------------------+-----------------------------------------+
| **CREDIT REPORT            | This acknowledgement is required for    |
| ACKNOWLEDGEMENT**          | all individual fiduciaries. Although a  |
|                            | prospective fiduciary may meet criteria |
|                            | for exemption from the credit report    |
|                            | requirement, they must acknowledge VA's |
|                            | authority to obtain a credit report.    |
+----------------------------+-----------------------------------------+
| **CRIMINAL BACKGROUND      | Any individual fiduciary must furnish a |
| INQUIRY**                  | statement regarding his or her criminal |
|                            | background. The form contains two       |
|                            | blocks:                                 |
|                            |                                         |
|                            | -   **"I have NEVER ben convicted of    |
|                            |     any offense under Federal or State  |
|                            |     law, which resulted in imprisonment |
|                            |     for more than one year," and**      |
|                            |                                         |
|                            | -   **"I have been convicted of an      |
|                            |     offense under Federal or State law, |
|                            |     which resulted in imprisonment for  |
|                            |     more than one year."**              |
|                            |                                         |
|                            |     The prospective fiduciary *must*    |
|                            |     initial the appropriate block.      |
+----------------------------+-----------------------------------------+
| **FIDUCIARY'S              |                                         |
| CERTIFICATION THAT         |                                         |
| STATEMENTS ON FORM ARE     |                                         |
| TRUE AND CORRECT**         |                                         |
+----------------------------+-----------------------------------------+
| **Signature**              | A *signature* is required. Printed name |
|                            | is not acceptable.                      |
+----------------------------+-----------------------------------------+
| **Date Signed**            | Self-explanatory.                       |
+----------------------------+-----------------------------------------+

[]{.mark}

+------------+---------------------------------------------------------+
| ##### d.   | > File the original form in the PGF with VA Form        |
| Filing and | > 21-555. It is generally suggested that is document be |
|  Retention | > filed on the flap containing computer generated       |
|            | > notices and payment records. Retain this form for the |
|            | > life of the PGF.                                      |
+------------+---------------------------------------------------------+

#### 8. VA Form 21-3045: Estate Action Record 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-3045 is used for recording actions taken   |
| a. What is | > and future diary dates.                               |
|  this form |                                                         |
|  used for? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Each PGF must contain VA Form 21-3045, Estate Action  |
| b. Use and | > Record. This form must be prepared when a PGF is      |
|  Retention | > established.                                          |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Use of VA Form 21-3045 ***is not optional.***           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Retain "filled forms" for the life of the PGF. They serve as a      |
| > "mini history" of case activity.                                    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** This is form is used exclusively within the Fiduciary   |
| > activity.                                                           |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The legal examiner generally enters the LAST NAME OF  |
| ### c. Com | > VETERAN, SOCIAL SECURITY NUMBER, and VA FILE NUMBER   |
| pletion in | > in the appropriate fields when s/he initially creates |
| structions | > a PGF. Any employee who deals with fiduciary matters  |
|            | > is responsible for recording these entries on         |
|            | > subsequent forms as they are added and for recording  |
|            | > actions they have taken. Refer to the following table |
|            | > for line-by-line completion instructions.             |
+------------+---------------------------------------------------------+

  -------------------------------- --------------------------------------
  Block# and Title                 Required Information

  **LAST NAME OF VETERAN**         Self-explanatory.

  **SOCIAL SECURITY NUMBER**       Self-explanatory.

  **VA FILE NUMBER**               Self-explanatory.
  -------------------------------- --------------------------------------

Continued on next page

8\. VA Form 21-3045: Estate Action Record, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+--------------------------------+-------------------------------------+
| Block# and Title               | Required Information                |
+--------------------------------+-------------------------------------+
| **NATURE OF ACTION**           | -   Enter a brief description of    |
|                                |     action taken. Augment with VA   |
|                                |     Form 119, Report of Contact, or |
|                                |     other appropriate documentation |
|                                |     when needed (e.g. "Additional   |
|                                |     bond requested; see 1/19/06     |
|                                |     letter to fiduciary," or        |
|                                |     "Veteran visited office;        |
|                                |     authorized \$20 increase in     |
|                                |     monthly incidental allowance.   |
|                                |     See VA Form 119 dated           |
|                                |     4/30/06").                      |
|                                |                                     |
|                                | -   Enter diary actions in          |
|                                |     chronological order. When       |
|                                |     miscellaneous diaries are       |
|                                |     entered in FBS, include a brief |
|                                |     description of the purpose for  |
|                                |     the diary to facilitate action  |
|                                |     when the diary date matures     |
|                                |     (i.e. "Account due 12/10/04,"   |
|                                |     "Next FBA due 10/10/09," or     |
|                                |     "MiscDue for reply to 1/8/06    |
|                                |     letter to fiduciary.").         |
|                                |                                     |
|                                | -   Enter a brief explanation of    |
|                                |     action taken when a diary       |
|                                |     matures (i.e., "Account         |
|                                |     approved, next account due      |
|                                |     12/10/07," or "4716a to FE").   |
|                                |                                     |
|                                | -   Record                          |
|                                |                                     |
|                                |     \- quality reviews,             |
|                                |                                     |
|                                |     \- referrals for legal review,  |
|                                |                                     |
|                                |     \- short note of telephone or   |
|                                |     personal                        |
|                                |                                     |
|                                |     interview, and                  |
|                                |                                     |
|                                |     \- mailing of accounting call   |
|                                |     letters.                        |
+--------------------------------+-------------------------------------+
| **DATE**                       | ***Always*** enter the date you     |
|                                | enter information.                  |
+--------------------------------+-------------------------------------+
| **INITIAL**                    | ***Always*** enter your initials    |
|                                | beside your entry and date.         |
+--------------------------------+-------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

Continued on next page

8\. VA Form 21-3045: Estate Action Record, Continued

+------------+---------------------------------------------------------+
| #####      | > Always use both sides of each form. Add additional    |
| d. Use and | > forms to the PGF as necessary. Retain all forms for   |
|  Retention | > the life of the PGF.                                  |
+------------+---------------------------------------------------------+

#### 9. VA Form 21-3190: Minor Beneficiary Field Examination Request and Report 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-3190 is a dual-purpose form used for:      |
| a. What is |                                                         |
|  this form | -   requesting a field examination for appointment of a |
|  used for? |     fiduciary for a minor child, and                    |
|            |                                                         |
|            | -   completion of a field examination report for a      |
|            |     minor child.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > VA Form 21-3190 is used to request field examinations |
| ## b. When | > for all minor beneficiaries under the supervision of  |
|  should th | > the F&FE Activity within VA.  It is manually prepared |
| is form be | > for use in the initial appointment field examination  |
|  prepared? | > and is computer generated for subsequent fiduciary    |
|            | > beneficiary field examinations.                       |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The field examiner's narrative report of field examination is also  |
| > completed on this form. Alternatively, the narrative report may be  |
| > completed on a separate page and referenced as an attachment on VA  |
| > Form 21-3190.                                                       |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c.   | > Office personnel or FBS will enter record information |
| General In | > on VA Form 21-3190 prior to assignment.               |
| structions |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The field examiner will                                             |
|                                                                       |
| -   review and verify all information supplied with the request and   |
|     enter on the face of the form any changes or additions developed  |
|     during the field examination,                                     |
|                                                                       |
| -   complete all items on the front of the form that are not          |
|     completed by office personnel or FBS, and                         |
|                                                                       |
| -   complete a narrative report of the field examination, explaining  |
|     any changes s/he has made to information on the face of the       |
|     report.                                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Information summarized on the front of VA Form 21-3190  |
| > must be complete and specific. Phrases such as "See Accounting,"    |
| > "See Report," 'As needed," and "See PGF" are not acceptable.        |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Brief reports for the sole use of the reporting       |
| d. Longhan | > Veterans Service Center may be written in longhand,   |
| d Reports  | > if they are legible.                                  |
+------------+---------------------------------------------------------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| #####      | > If the report includes information to be referred to  |
| e. Copies  | > another Veteran Service Center element and/or another |
| of Reports | > activity (i.e. VAMC, Insurance Center, etc.),         |
|            | > annotate Item 19 with instructions for referral.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Refer to the following table to determine minimum     |
| # f. Attac | > attachments for minor child field examination         |
| hments --  | > ***requests***:                                       |
| Field Exam |                                                         |
|  Requests  |                                                         |
+------------+---------------------------------------------------------+

+-----------------------+----------------------------------------------+
| If the field          | You must include the following ...           |
| examination request   |                                              |
| is ...                |                                              |
+-----------------------+----------------------------------------------+
| an IA field exam      | -   VA Form 21-592,                          |
| request               |                                              |
|                       | -   current electronic payment record, if    |
|                       |     applicable, and                          |
|                       |                                              |
|                       | -   any documents provided with VA Form      |
|                       |     21-592 (i.e. Letters of Guardianship,    |
|                       |     letters from potential fiduciaries,      |
|                       |     etc.).                                   |
+-----------------------+----------------------------------------------+
| a                     | -   copy of the last field examination       |
| fiduciary-beneficiary |     report,                                  |
| field exam request    |                                              |
|                       | -   current electronic payment record, if    |
|                       |     applicable, and                          |
|                       |                                              |
|                       | -   any other pertinent documents or         |
|                       |     correspondence indicating the need for   |
|                       |     advice or assistance.                    |
+-----------------------+----------------------------------------------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  f\. Attachments -- Field Exam Requests (continued)

  -----------------------------------------------------------------------

+-----------------------+----------------------------------------------+
| If the field          | You must include the following ...           |
| examination request   |                                              |
| is ...                |                                              |
+-----------------------+----------------------------------------------+
| an unscheduled        | -   a specific statement of the reason for   |
| fiduciary-beneficiary |     the unscheduled field examination        |
| field exam request    |     request,                                 |
|                       |                                              |
|                       | -   a copy of the last field examination     |
|                       |     report,                                  |
|                       |                                              |
|                       | -   current electronic payment record, if    |
|                       |     applicable, and                          |
|                       |                                              |
|                       | -   any other pertinent documents or         |
|                       |     correspondence to support the request.   |
+-----------------------+----------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The field examiner's completed report will include,   |
| ### g. Att | > at the beginning of the report narrative, a list of   |
| achments - | > all attachments that are being submitted with the     |
| - Field Ex | > report. This list will include such items as:         |
| am Reports |                                                         |
|            | -   VA Form 119, Report of Contact,                     |
|            |                                                         |
|            | -   sworn statements,                                   |
|            |                                                         |
|            | -   birth certificates,                                 |
|            |                                                         |
|            | -   custodial documents, and                            |
|            |                                                         |
|            | -   other documents, obtained during the field          |
|            |     examination that were requested by the requesting   |
|            |     element.                                            |
+------------+---------------------------------------------------------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### h. Com | > completion instructions:                              |
| pletion In |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

+------------+----------------------------+---------------+-----------+
| Field \#   | Required Data              | IA and        | Scheduled |
| and Name   |                            | Unscheduled   | FB Exam   |
|            |                            | FB            |           |
+------------+----------------------------+---------------+-----------+
| **TO**     | Enter the address of the   | Office        | FBS       |
|            | Fiduciary and Field        | Personnel     | auto-fill |
|            | Examination Activity that  |               |           |
|            | will complete the field    |               |           |
|            | examination                |               |           |
+------------+----------------------------+---------------+-----------+
| **1. DATE  | Enter date the request is  | Office        | FBS       |
| OF         | received in the F&FE       | Personnel     | auto-fill |
| REQUEST**  | activity. Examples include |               |           |
|            | but are no limited to the  | **DO NOT      | **DO NOT  |
|            | following:                 | CHANGE**      | CHANGE    |
|            |                            |               | unless FB |
|            | -   date VA Form 21-592    |               | field     |
|            |     *is received* by F&FE  |               | exam is   |
|            |     (per date stamp)       |               | changed   |
|            |                            |               | to a      |
|            | -   date of telephone call |               | successor |
|            |     requesting appointment |               | app       |
|            |     of a successor         |               | oint-ment |
|            |     fiduciary              |               | field     |
|            |                            |               | exam**    |
|            | -   date allegation of     |               |           |
|            |     misuse is received,    |               |           |
|            |                            |               |           |
|            | -   date potential misuse  |               |           |
|            |     is discovered by VA,   |               |           |
|            |                            |               |           |
|            | -   date accounting is     |               |           |
|            |     received by F&FE (per  |               |           |
|            |     date stamp)            |               |           |
|            |                            |               |           |
|            | -   date of notice of      |               |           |
|            |     death of a fiduciary   |               |           |
|            |     is received by F&FE    |               |           |
|            |     (per date stamp)       |               |           |
+------------+----------------------------+---------------+-----------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+------------+----------------------------+---------------+-----------+
| Field \#   | Required Data              | IA and        | Scheduled |
| and Name   |                            | Unscheduled   | FB Exam   |
|            |                            | FB            |           |
+------------+----------------------------+---------------+-----------+
| **2. TYPE  | Enter a checkmark in the   | Office        | FBS       |
| OF FIELD   | "INITIAL" block for        | Personnel     | auto-fill |
| EXAM       | initial appointment field  |               |           |
| IN-ATION** | exam request (to include   |               |           |
|            | request for a successor    |               |           |
|            | appointment).              |               |           |
|            |                            |               |           |
|            | FBS automatically enters   |               |           |
|            | "P" for personal contact   |               |           |
|            | and "A" for alternate      |               |           |
|            | contact in the "FID BEN"   |               |           |
|            | block for scheduled        |               |           |
|            | fiduciary-beneficiary exam |               |           |
|            | requests.                  |               |           |
+------------+----------------------------+---------------+-----------+
| **3.       | Enter the veteran's Social | Office        | FBS       |
| SOCIAL     | Security number.           | Personnel     | auto-fill |
| SECURITY   |                            |               |           |
| NUMBER**   |                            |               |           |
+------------+----------------------------+---------------+-----------+
| **4. VA    | Self-explanatory           | Office        | FBS       |
| FILE       |                            | Personnel     | auto-fill |
| NUMBER**   |                            |               |           |
+------------+----------------------------+---------------+-----------+
| **5. NAME  | Self-explanatory           | Office        | FBS       |
| OF         |                            | Personnel     | auto-fill |
| VETERAN**  |                            |               |           |
+------------+----------------------------+---------------+-----------+
| **6. TYPE  | Enter check in appropriate | Blank if IA   | FBS       |
| OF         | block to designate the     |               | auto-fill |
| F          | type of fiduciary          | Office        |           |
| IDUCIARY** | appointment.               | Personnel     |           |
|            |                            |               |           |
|            |                            | if            |           |
|            |                            | Unscheduled   |           |
+------------+----------------------------+---------------+-----------+
| **7A. NAME | Enter the name and address | FE Blank if   | FBS       |
| AND        | of the fiduciary as it     | IA            | auto-fill |
| ADDRESS OF | appears in payment         |               |           |
| F          | records.                   | Office        |           |
| IDUCIARY** |                            | Personnel     |           |
|            |                            |               |           |
|            |                            | if            |           |
|            |                            | Unscheduled   |           |
+------------+----------------------------+---------------+-----------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ---------------- ---------------------------- ---------------- ------------
  Field \# and     Required Data                IA and           Scheduled FB
  Name                                          Unscheduled FB   Exam

  **7B. TELE-PHONE Self-explanatory             FE               FBS
  NUMBER OF                                                      auto-fill
  FIDUCIARY**                                                    

  **7C. SOCIAL     Self-explanatory             FE               FBS
  SECURITY NUMBER                                                auto-fill
  OF FIDUCIARY**                                                 

  **7D.            Enter the fiduciary's        FE               Office
  RELA-TIONSHIP    relationship to the child.                    Personnel or
  (IF ANY)**       If not related, enter "none"                  FE
                   or "N/A."                                     

  **7E. DIRECT     Enter check in appropriate   FE               Office
  DEPOSIT**        block to indicate if                          Personnel or
                   benefits are currently                        FE
                   direct deposited.                             

  **8A. ADDRESS OF Enter beneficiary's address, FE               FBS
  BENEFI-CIARY**   if different from fiduciary                   auto-fill

  **8B. NAME OF    Self-explanatory. In IA      Office Personnel Office
  PERSON HAVING    cases, this information can                   Personnel or
  CUSTODY**        generally be found on the VA                  FE
                   Form 21-592.                                  
  ---------------- ---------------------------- ---------------- ------------

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  --------------- ----------------------------- --------------- ------------
  Field \# and    Required Data                 IA and          Scheduled FB
  Name                                          Unscheduled FB  Exam

  **8C.           Self-explanatory.             Office          FBS
  TELE-PHONE                                    Personnel       auto-fill
  NUMBERS**                                                     

  **8D.           Enter the custodian's         Office          Office
  RELA-TIONSHIP   relationship to the child. If Personnel       Personnel or
  (IF ANY)**      not related, enter "none" or                  FE
                  "N/A."                                        

  **9A. FIRST     Enter information from VA     Office          FBS
  NAME**          Form 21-592 for each minor.   Personnel       auto-fill

                  FE enters a checkmark beside  FE              FE
                  the first name of each minor                  
                  actually seen. When there is                  
                  no check mark, the FE will                    
                  explain the reason in Item                    
                  20.                                           

  **9B. LAST      Enter for each minor          Office          FBS
  NAME**          ***only*** if last name is    Personnel       auto-fill
                  different from that of the                    
                  veteran. Obtain information                   
                  from VA Form 21-592.                          

  **9C. BIRTH     Enter information from VA     Office          Office
  DATE**          Form 21-592 for each minor.   Personnel       Personnel

  **9D.           Enter territorial code        Office          FBS
  TERRI-TORIAL    assigned to the area where    Personnel       auto-fill
  CODE**          the beneficiary resides.                      
                  Refer to the FBS User Guide,                  
                  Chapter 8 for specific                        
                  instructions on Territorial                   
                  Code assignments                              

  **10. MONTHLY   For each minor, enter the     Office          Office
  PAY-MENTS**     type and monthly amount of VA Personnel       Personnel
                  benefits, Social Security,                    
                  and any other known income.                   
  --------------- ----------------------------- --------------- ------------

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+------------+----------------------------+--------------+------------+
| Field \#   | Required Data              | IA and       | Scheduled  |
| and Name   |                            | Unscheduled  | FB Exam    |
|            |                            | FB           |            |
+------------+----------------------------+--------------+------------+
| **11.      | For each minor, check      | FE           | FE         |
| ESTATE**   | "Protected" for any minor  |              |            |
|            | whose estate is protected. |              |            |
|            | An estate may be protected |              |            |
|            | by                         |              |            |
|            |                            |              |            |
|            | -   a court order,         |              |            |
|            |                            |              |            |
|            | -   withdrawal agreement,  |              |            |
|            |     or                     |              |            |
|            |                            |              |            |
|            | -   properly registered    |              |            |
|            |     U.S. Savings Bonds.    |              |            |
+------------+----------------------------+--------------+------------+
| **12.      | For IA requests, list      | FE           |            |
| EXPEN      | monthly and nonrecurrent   |              |            |
| DI-TURES** | expenditures for each      |              |            |
|            | minor agreed upon after    |              |            |
|            | discussion with the        |              |            |
|            | fiduciary.                 |              |            |
+------------+----------------------------+--------------+------------+
|            | For FB requests, enter the |              | Office     |
|            | amount of monthly          |              | Personnel  |
|            | nonrecurrent expenditures  |              |            |
|            | from VA benefits only if   |              |            |
|            | other information in the   |              |            |
|            | PGF indicates that it is   |              |            |
|            | different than the amount  |              |            |
|            | shown on the previous      |              |            |
|            | field examination.         |              |            |
|            | Otherwise, leave blank.    |              |            |
+------------+----------------------------+--------------+------------+
| **13A.     | State each minor's grade   | FE           | FE         |
| PRESENT    | level. If a field          |              |            |
| SCHOOL     | examination is conducted   |              |            |
| GRADE**    | during summer vacation,    |              |            |
|            | show the grade the child   |              |            |
|            | will start the next school |              |            |
|            | year. If grade is other    |              |            |
|            | than normal for a child of |              |            |
|            | that age, explain in the   |              |            |
|            | report narrative and       |              |            |
|            | include the name of the    |              |            |
|            | school the child is        |              |            |
|            | attending.                 |              |            |
+------------+----------------------------+--------------+------------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  -------------- ----------------------------- --------------- ------------
  Field \# and   Required Data                 IA and          Scheduled FB
  Name                                         Unscheduled FB  Exam

  **13B. FUTURE  For each minor, state the     FE              FE
  EDUC PLANS**   type of school contemplated                   
                 for education or training                     
                 beyond high school and the                    
                 number of years of required                   
                 attendance, if minor is at an                 
                 age where such plans have                     
                 been made.                                    

  **14. ACTION                                                 
  REQUIRED                                                     
  fields:**                                                    
  Insert the                                                   
  diary date of                                                
  future actions                                               
  necessary for                                                
  each minor, in                                               
  as many of the                                               
  categories as                                                
  appropriate.                                                 
  Future actions                                               
  will be                                                      
  scheduled in                                                 
  accordance                                                   
  with                                                         
  procedures                                                   
  discussed in                                                 
  the Fiduciary                                                
  Program                                                      
  Manual.                                                      

  **14A. CLOSE** For each child, enter the     FE              FE
                 date the PGF should be                        
                 closed.                                       

  **14B. AWARD   For each child that will      FE              FE
  FOLLOWUP**     likely be entitled to                         
                 benefits beyond age 18, enter                 
                 a date 30 days prior to age                   
                 18 to review for award action                 
                 to continue benefits                          

  **14C. LETTER  For each child whose          FE              FE
  AT MAJORITY**  fiduciary has an estate that                  
                 includes VA-derived funds,                    
                 enter the child's 18^th^                      
                 birth date to generate an                     
                 instructional letter to the                   
                 fiduciary to ensure VA funds                  
                 are transferred to the child                  
                 timely.                                       
  -------------- ----------------------------- --------------- ------------

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+----------+---+----------+----------+-----------+---+---------+---+---------+
|          |   | Field \# | Required |           |   | IA and  |   | Sc      |
|          |   | and Name | Data     |           |   | Unsc    |   | heduled |
|          |   |          |          |           |   | heduled |   | FB Exam |
|          |   |          |          |           |   | FB      |   |         |
+----------+---+----------+----------+-----------+---+---------+---+---------+
|          |   | **14D.   | For each |           |   | FE      |   | FE      |
|          |   | FID      | minor    |           |   |         |   |         |
|          |   | U-CIARY/ | child,   |           |   |         |   |         |
|          |   | BENE-F   | enter an |           |   |         |   |         |
|          |   | ICIARY** | app      |           |   |         |   |         |
|          |   |          | ropriate |           |   |         |   |         |
|          |   |          | date for |           |   |         |   |         |
|          |   |          | sc       |           |   |         |   |         |
|          |   |          | heduling |           |   |         |   |         |
|          |   |          | the next |           |   |         |   |         |
|          |   |          | fid-ben  |           |   |         |   |         |
|          |   |          | field    |           |   |         |   |         |
|          |   |          | exam     |           |   |         |   |         |
|          |   |          | when it  |           |   |         |   |         |
|          |   |          | appears  |           |   |         |   |         |
|          |   |          | the      |           |   |         |   |         |
|          |   |          | child    |           |   |         |   |         |
|          |   |          | may be   |           |   |         |   |         |
|          |   |          | entitled |           |   |         |   |         |
|          |   |          | to VA    |           |   |         |   |         |
|          |   |          | benefits |           |   |         |   |         |
|          |   |          | beyond   |           |   |         |   |         |
|          |   |          | age 18.  |           |   |         |   |         |
+----------+---+----------+----------+-----------+---+---------+---+---------+
| **14E.   | F |          |          | FE        | F |         |   |         |
| REVIEW   | o |          |          |           | E |         |   |         |
| PGF**    | r |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | c |          |          |           |   |         |   |         |
|          | h |          |          |           |   |         |   |         |
|          | m |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | o |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | c |          |          |           |   |         |   |         |
|          | h |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | l |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
|          | f |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | l |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | x |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | m |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | v |          |          |           |   |         |   |         |
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|          | v |          |          |           |   |         |   |         |
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|          | F |          |          |           |   |         |   |         |
|          | R |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
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|          | i |          |          |           |   |         |   |         |
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|          |   |          |          |           |   |         |   |         |
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|          | 2 |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
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|          |   |          |          |           |   |         |   |         |
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|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
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|          |   |          |          |           |   |         |   |         |
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|          | r |          |          |           |   |         |   |         |
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|          | i |          |          |           |   |         |   |         |
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|          | d |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
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|          |   |          |          |           |   |         |   |         |
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|          | e |          |          |           |   |         |   |         |
|          | x |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | m |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | s |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          | s |          |          |           |   |         |   |         |
|          | c |          |          |           |   |         |   |         |
|          | h |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
|          | u |          |          |           |   |         |   |         |
|          | l |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
|          | . |          |          |           |   |         |   |         |
|          |   |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | N |          |          |           |   |         |   |         |
|          | O |          |          |           |   |         |   |         |
|          | T |          |          |           |   |         |   |         |
|          | E |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | * |          |          |           |   |         |   |         |
|          | : |          |          |           |   |         |   |         |
|          | T |          |          |           |   |         |   |         |
|          | h |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | f |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
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|          | d |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
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|          | a |          |          |           |   |         |   |         |
|          | m |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
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|          | o |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | a |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | v |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | m |          |          |           |   |         |   |         |
|          | u |          |          |           |   |         |   |         |
|          | s |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | c |          |          |           |   |         |   |         |
|          | l |          |          |           |   |         |   |         |
|          | u |          |          |           |   |         |   |         |
|          | d |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | s |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | u |          |          |           |   |         |   |         |
|          | c |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | o |          |          |           |   |         |   |         |
|          | n |          |          |           |   |         |   |         |
|          | s |          |          |           |   |         |   |         |
|          | f |          |          |           |   |         |   |         |
|          | o |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | t |          |          |           |   |         |   |         |
|          | h |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | P |          |          |           |   |         |   |         |
|          | G |          |          |           |   |         |   |         |
|          | F |          |          |           |   |         |   |         |
|          | r |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | v |          |          |           |   |         |   |         |
|          | i |          |          |           |   |         |   |         |
|          | e |          |          |           |   |         |   |         |
|          | w |          |          |           |   |         |   |         |
|          | . |          |          |           |   |         |   |         |
+----------+---+----------+----------+-----------+---+---------+---+---------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  --------------- ---------------------------- --------------- ------------
  Field \# and    Required Data                IA and          Scheduled FB
  Name                                         Unscheduled FB  Exam

  **15. OTHER                                                  
  FAMILY INCOME                                                
  AND FAMILY                                                   
  EXPENSE                                                      
  *(Average                                                    
  Monthly)*:**                                                 
  The FE will try                                              
  to obtain                                                    
  accurate                                                     
  estimates of                                                 
  the monthly                                                  
  income and                                                   
  expenses of the                                              
  person having                                                
  custody of the                                               
  minor if that                                                
  person is                                                    
  legally                                                      
  obligated to                                                 
  support the                                                  
  minor. When the                                              
  parent or other                                              
  person having                                                
  custody of the                                               
  minor is unable                                              
  or reluctant to                                              
  furnish income                                               
  or expense                                                   
  information, an                                              
  estimate based                                               
  on the observed                                              
  standard of                                                  
  living will                                                  
  suffice. If an                                               
  estimate is                                                  
  necessary, a                                                 
  concise                                                      
  description of                                               
  the standard of                                              
  living must be                                               
  included in the                                              
  narrative                                                    
  report. If a                                                 
  particular                                                   
  field is not                                                 
  applicable,                                                  
  enter "N/A."                                                 

  **15A. PARENT** If the child (or children)   FE              FE
                  resides with a natural                       
                  parent, enter the parent's                   
                  average monthly income.                      

  **15B.          If the child (or children)   FE              FE
  STEP-PARENT**   resides with a stepparent,                   
                  enter the stepparent's                       
                  average monthly income.                      

  **15C. OTHER**  Enter other household        FE              FE
                  income. Identify the source                  
                  of this income in the report                 
                  narrative.                                   

  **15D. TOTAL    Enter the total of items 15A FE              FE
  INCOME**        through 15D.                                 

  **15E. ARE      Check appropriate block      FE              FE
  OTHER MEMBERS   ("YES" or "NO") to reflect                   
  OF HOUSE-HOLD   whether other household                      
  DEPEN-DENT ON   members are dependent on                     
  FAMILY          family income. Identify                      
  INCOME?**       other dependent household                    
                  members in the report                        
                  narrative.                                   
  --------------- ---------------------------- --------------- ------------

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+----------------------------+--------------+-----------+
| Field \#    | Required Data              | IA and       | Scheduled |
| and Name    |                            | Unscheduled  | FB Exam   |
|             |                            | FB           |           |
+-------------+----------------------------+--------------+-----------+
| **15F.      | Enter average monthly      | FE           | FE        |
| AVERAGE     | family expense as reported |              |           |
| FAMILY      | by the fiduciary.          |              |           |
| MONTHLY     |                            |              |           |
| EXPENSES**  |                            |              |           |
+-------------+----------------------------+--------------+-----------+
| **16A. HAS  | Check applicable block to  | FE           | FE        |
| A PAYEE     | indicate whether a payee   |              |           |
| BEEN        | has been designated.       |              |           |
| DES         |                            |              |           |
| IG-NATED?** |                            |              |           |
+-------------+----------------------------+--------------+-----------+
| **16B. TYPE | If "YES\" entered in 16A,  | FE           | FE        |
| OF PAYEE    | check applicable block to  |              |           |
| DES         | identify                   |              |           |
| IG-NATION** |                            |              |           |
|             | -   the type of            |              |           |
|             |     appointment (initial   |              |           |
|             |     or successor),         |              |           |
|             |                            |              |           |
|             | -   what completed forms   |              |           |
|             |     are attached, and      |              |           |
|             |                            |              |           |
|             | -   whether action must be |              |           |
|             |     taken by office        |              |           |
|             |     personnel to certify a |              |           |
|             |     fiduciary.             |              |           |
+-------------+----------------------------+--------------+-----------+
| **17. FORMS | Check applicable blocks to | FE           | FE        |
| COMPLET-ED  | identify any forms that    |              |           |
| OR LEFT     | were completed or left     |              |           |
| WITH        | with the fiduciary. If     |              |           |
| FIDUCIARY** | "OTHER" is selected,       |              |           |
|             | identify attached          |              |           |
|             | documents.                 |              |           |
+-------------+----------------------------+--------------+-----------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+----------------------------+--------------+-----------+
| Field \#    | Required Data              | IA and       | Scheduled |
| and Name    |                            | Unscheduled  | FB Exam   |
|             |                            | FB           |           |
+-------------+----------------------------+--------------+-----------+
| **18.       |                            |              |           |
| STATISTICAL |                            |              |           |
| TREND       |                            |              |           |
| DATA.** The |                            |              |           |
| FE will     |                            |              |           |
| complete    |                            |              |           |
| each        |                            |              |           |
| applicable  |                            |              |           |
| block and   |                            |              |           |
| incorporate |                            |              |           |
| supporting  |                            |              |           |
| evidence    |                            |              |           |
| into the    |                            |              |           |
| report      |                            |              |           |
| narrative.  |                            |              |           |
| The FE will |                            |              |           |
| include     |                            |              |           |
| i           |                            |              |           |
| nstructions |                            |              |           |
| in Item 19  |                            |              |           |
| when        |                            |              |           |
| referral to |                            |              |           |
| the Office  |                            |              |           |
| of          |                            |              |           |
| Inspector   |                            |              |           |
| General     |                            |              |           |
| (OIG) or    |                            |              |           |
| Regional    |                            |              |           |
| Counsel     |                            |              |           |
| (RC) is     |                            |              |           |
| necessary   |                            |              |           |
| to ensure   |                            |              |           |
| that these  |                            |              |           |
| cases are   |                            |              |           |
| first       |                            |              |           |
| referred to |                            |              |           |
| an LIE.     |                            |              |           |
+-------------+----------------------------+--------------+-----------+
| **18A.      | Check this block if any    | FE           | FE        |
| ADVERSE     | unhealthy or unacceptable  |              |           |
| C           | living conditions are      |              |           |
| ONDI-TION** | identified which affect    |              |           |
|             | the beneficiary. If this   |              |           |
|             | block is checked, the      |              |           |
|             | narrative must include a   |              |           |
|             | full description of:       |              |           |
|             |                            |              |           |
|             | -   the adverse condition, |              |           |
|             |     and                    |              |           |
|             |                            |              |           |
|             | -   steps taken to correct |              |           |
|             |     the situation.         |              |           |
+-------------+----------------------------+--------------+-----------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+---------------------------+---+--------------+-----------+
| Field \#    | Required Data             |   | IA and       | Scheduled |
| and Name    |                           |   | Unscheduled  | FB Exam   |
|             |                           |   | FB           |           |
+-------------+---------------------------+---+--------------+-----------+
| **18B.      | Do not check the "VA"     | F |              | FE        |
| MISUSE OF   | block on this form, as    | E |              |           |
| FUNDS**     | misuse of VA funds can    |   |              |           |
|             | only be determined after  |   |              |           |
|             | a thorough fact-finding   |   |              |           |
|             | investigation and formal  |   |              |           |
|             | determination by the      |   |              |           |
|             | VSCM. If the FE           |   |              |           |
|             | identifies potential      |   |              |           |
|             | misuse of VA benefits     |   |              |           |
|             | during a field            |   |              |           |
|             | examination, s/he will    |   |              |           |
|             | immediately refer all     |   |              |           |
|             | known facts to the F&FE   |   |              |           |
|             | supervisor who will       |   |              |           |
|             | determine if sufficient   |   |              |           |
|             | information exists to     |   |              |           |
|             | warrant a misuse          |   |              |           |
|             | investigation. This       |   |              |           |
|             | referral may be by email, |   |              |           |
|             | telephone call, informal  |   |              |           |
|             | memo, or other suitable   |   |              |           |
|             | means. The facts, as      |   |              |           |
|             | know, will also be        |   |              |           |
|             | included in the FB        |   |              |           |
|             | narrative.                |   |              |           |
|             |                           |   |              |           |
|             | If misuse of "OTHER       |   |              |           |
|             | GOV'T" or                 |   |              |           |
|             |                           |   |              |           |
|             | "OTHER UNIDENTIFIED"      |   |              |           |
|             | funds is identified,      |   |              |           |
|             | check the appropriate     |   |              |           |
|             | block and enter the       |   |              |           |
|             | estimated amount of       |   |              |           |
|             | misused funds in the      |   |              |           |
|             | corresponding amount      |   |              |           |
|             | field.                    |   |              |           |
+-------------+---------------------------+---+--------------+-----------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ----------------- ---------------------------- ---- --------------- ------------
  Field \# and Name Required Data                     IA and          Scheduled FB
                                                      Unscheduled FB  Exam

  **18C. CASE TO BE Check this block if the case FE                   FE
  REFER-RED TO RC** is to be referred to the                          
                    Regional Counsel for legal                        
                    action, and enter the total                       
                    estimated dollar amount in                        
                    the corresponding amount                          
                    field.                                            

  **18D. CASE TO BE Do not check the IG referral FE                   FE
  REFER-RED TO IG** block on this form. Cases                         
                    will be referred to the IG                        
                    only after a thorough                             
                    fact-finding investigation                        
                    and formal determination by                       
                    the VSCM.                                         

  **18E. POSSIBLE   Check this block if any      FE                   FE
  OVER-PAYMENT**    possible overpayment in VA                        
                    benefits is identified and                        
                    indicate where the case is                        
                    to be referred for action.                        

  **18F. POSSIBLE   Check this block if any      FE                   FE
  UNDER-PAYMENT**   possible underpayment in VA                       
                    benefits is identified and                        
                    indicate where the case is                        
                    to be referred for action.                        
  ----------------- ---------------------------- ---- --------------- ------------

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+----------------------------+--------------+-----------+
| Field \#    | Required Data              | IA and       | Scheduled |
| and Name    |                            | Unscheduled  | FB Exam   |
|             |                            | FB           |           |
+-------------+----------------------------+--------------+-----------+
| **19.       | Enter any special          | FE           | FE        |
| ACTION      | instructions to office     |              |           |
| REQUIRED    | personnel. Instructions    |              |           |
| OTHER THAN  | should include sufficient  |              |           |
| SHOWN IN    | information to show        |              |           |
| ITEMS 14    | clearly what is to be done |              |           |
| AND 15**    | and by whom.               |              |           |
|             |                            |              |           |
|             | ***Note:*** Future actions |              |           |
|             | specified in Items 14 and  |              |           |
|             | 15 should not be included  |              |           |
|             | here.                      |              |           |
+-------------+----------------------------+--------------+-----------+
| **20.       | Enter special instructions | Office       | Office    |
| COM-MENTS** | or information for field   | Personnel    | Personnel |
|             | examiner, if any, with the |              |           |
|             | request for field          |              |           |
|             | examination.               |              |           |
+-------------+----------------------------+--------------+-----------+
|             | Enter narrative to address |              |           |
|             | all essential elements of  |              |           |
|             | the minor child field      |              |           |
|             | examination as discussed   |              |           |
|             | in the Fiduciary Program   |              |           |
|             | Manual.                    |              |           |
+-------------+----------------------------+--------------+-----------+
| **21A.      | Signature and office       | FE           | FE        |
| SIGNA-TURE  | identification of field    |              |           |
| OF          | examiner or other          |              |           |
| AUTHOR-IZED | individual completing the  |              |           |
| OFFICIAL    | field examination.         |              |           |
| AND         |                            |              |           |
| OFFICE**    |                            |              |           |
+-------------+----------------------------+--------------+-----------+
| **21B. DATE | Enter the date report is   | FE           | FE        |
| OF REPORT** | signed.                    |              |           |
+-------------+----------------------------+--------------+-----------+

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

Continued on next page

9\. VA Form 21-3190: Minor Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| ##### i.   | > File the original, completed VA Form 21-3190 in the   |
| Filing and | > PGF. Each FB, scheduled or unscheduled, will include  |
|  Retention | > a photocopy of the most recent report; the original   |
|            | > must remain in the PGF at all times. Retain for the   |
|            | > life of the file.                                     |
+------------+---------------------------------------------------------+

#### 10. VA Form 21-3537a: Field Examination Request 

+------------+---------------------------------------------------------+
| #####      | VA Form 21-3537a is used for preparation of field       |
| a. What is | examination requests that involve                       |
|  this form |                                                         |
|  used for? | -   program field examinations (i.e. unscheduled,       |
|            |     misuse, or onsite review), when a full fid-ben      |
|            |     review is not warranted,                            |
|            |                                                         |
|            | -   non-program field examinations, or                  |
|            |                                                         |
|            | -   special field examinations.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Prepare VA Form 21-3537a when:                        |
| ## b. When |                                                         |
|  should th | -   an LIE desires field investigation to obtain        |
| is form be |     information from a fiduciary (or beneficiary) in    |
|  prepared? |     support of an accounting, or to determine the       |
|            |     validity of a request for expenditure from the      |
|            |     estate of an incompetent beneficiary,               |
|            |                                                         |
|            | -   a manager determines a misuse investigation is      |
|            |     indicated,                                          |
|            |                                                         |
|            | -   a VSR desires field investigation to develop issues |
|            |     relevant to a beneficiary's entitlement (or         |
|            |     continued entitlement) to benefits.                 |
|            |                                                         |
|            | -   a VSR desires investigation of potential fraudulent |
|            |     behavior by a beneficiary, or                       |
|            |                                                         |
|            | -   any other instance when field investigation is      |
|            |     desirable.                                          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **ORIGINATING OFFICE**         the name and/or routing symbol of the
                                 office requesting the field examination.

  **SOCIAL SECURITY NUMBER**     the veteran's Social Security number

  **VA FILE NO.**                the veteran's VA claim number.

  **DATE OF REQUEST**            the date the request is prepared and
                                 referred to the Fiduciary & Field
                                 Examination Activity.

  **FROM**                       the office designation (i.e. VARO, etc.)
                                 and mailing address for the office that
                                 is requesting the field examination.

  **NAME OF VETERAN**            the veteran's full name.

  **NAME OF CLAIMANT**           the claimant's full name.

  **TO**                         the office designation (i.e. VARO, etc.)
                                 and mailing address for the office that
                                 will conduct the field examination.
  ------------------------------ ----------------------------------------

Continued on next page

10\. VA Form 21-3537a: Field Examination Request, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **ADDRESS OF CLAIMANT**     | the claimant's physical address; do    |
|                             | not enter P. O. Box or similar         |
|                             | non-specific addresses.                |
+-----------------------------+----------------------------------------+
| **FACTS TO BE ESTABLISHED** | -   a summary of the situation that    |
|                             |     resulted in the field examination  |
|                             |     request,                           |
|                             |                                        |
|                             | -   all known facts,                   |
|                             |                                        |
|                             | -   an itemization of any supporting   |
|                             |     attachments, and                   |
|                             |                                        |
|                             | -   the specific elements the FE is    |
|                             |     expected to address.               |
+-----------------------------+----------------------------------------+

+-----------------------------------------------------------------------+
| > ***Notes:***                                                        |
|                                                                       |
| 1.  Entry is required in all fields in all cases.                     |
|                                                                       |
| 2.  Consider providing these instructions to other elements that      |
|     > routinely request field examinations, to facilitate acceptable  |
|     > requests and eliminate unnecessary action by the field examiner |
|     > to develop for missing information.                             |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > Refer to the following table for filing and retention |
| Filing and | > instructions:                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| If the request involves a ...    | Use the following instructions:   |
+----------------------------------+-----------------------------------+
| program field examination        | File the original report in the   |
|                                  | PGF and retain it for the life of |
|                                  | the file.                         |
+----------------------------------+-----------------------------------+
| non-program, or special field    | -   Refer the original request to |
| examination                      |     the requesting element with   |
|                                  |     the completed report, and     |
|                                  |                                   |
|                                  | -   retain a copy of the request  |
|                                  |     in the F&FE Activity          |
|                                  |     correspondence or VetsFile,   |
|                                  |     as appropriate.               |
+----------------------------------+-----------------------------------+

#### 11. VA Form 21-3537b: Field Examination Report 

+------------+---------------------------------------------------------+
| #####      | VA Form 21-3537b is used by the field examiner to       |
| a. What is | prepare his or her report of contacts made, facts       |
|  this form | developed and actions taken in                          |
|  used for? |                                                         |
|            | -   unscheduled field examinations when a full FB is    |
|            |     not conducted, and                                  |
|            |                                                         |
|            | -   non-program and special field examinations.         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** This is the "partner" form to the VA Form 21-3537a.     |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Prepare VA Form 21-3537b when you have completed the  |
| ## b. When | > requested investigation to the extent possible within |
|  should th | > your jurisdiction.                                    |
| is form be |                                                         |
|  prepared? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ------------------------------ ----------------------------------------
  In block titled ...            Enter ...

  **1. VETERAN'S NAME**          Self-explanatory.

  **2. DATE OF REQUEST**         the date of the request for field
                                 examination.

  **3. VA FILE NO.**             Self-explanatory.

  **4. SOCIAL SECURITY NUMBER**  the veteran's Social Security Number

  **5. ORIGINATING OFFICE**      the office designation (i.e. VARO, etc.)
                                 and mailing address for the office that
                                 requested the field examination.

  **6. REPORTING**               the office designation (i.e. VARO, etc.)
                                 and mailing address for the office that
                                 conducted the field examination.

  **7. REPORT MADE BY**          your name ***and SIGNATURE***.
  ------------------------------ ----------------------------------------

Continued on next page

11\. VA Form 21-3537b: Field Examination Report, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| In block titled ...         | Enter ...                              |
+-----------------------------+----------------------------------------+
| **8. DATE OF REPORT**       | the date you complete and submit the   |
|                             | report. This will generally be the     |
|                             | date you sign the report.              |
+-----------------------------+----------------------------------------+
| **9. PURPOSE**              | the narrative portion of your report.  |
|                             | It must include sections identified by |
|                             | the following headings:                |
|                             |                                        |
|                             | -   **PURPOSE**: A brief summary of    |
|                             |     the purpose of the field           |
|                             |     examination request.               |
|                             |                                        |
|                             | -   **ATTACHMENTS**: An itemization of |
|                             |     any supporting material attached   |
|                             |     to the report (see subparagraph    |
|                             |     10d below).                        |
|                             |                                        |
|                             | -   **COMMENTS**: A cross-reference to |
|                             |     the attachments may be made in     |
|                             |     this section (see subparagraph 10e |
|                             |     below).                            |
|                             |                                        |
|                             | -   **NARRATIVE**: A summary of report |
|                             |     of the investigation, with         |
|                             |     cross-reference to attachments as  |
|                             |     appropriate.                       |
|                             |                                        |
|                             | -   **RECOMMENDATIONS**: Conclusion of |
|                             |     the report. Includes specific      |
|                             |     recommendations when:              |
|                             |                                        |
|                             |     \- Further field examination is    |
|                             |     required,                          |
|                             |                                        |
|                             |     \- It appears criminal wrongdoing  |
|                             |     is                                 |
|                             |                                        |
|                             |     involved,                          |
|                             |                                        |
|                             |     \- It appears that false or        |
|                             |     fraudulent                         |
|                             |                                        |
|                             |     evidence has been submitted, or    |
|                             |                                        |
|                             |     \- Recommendations were            |
|                             |     specifically                       |
|                             |                                        |
|                             |     requested or otherwise indicated.  |
+-----------------------------+----------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Entry is required in all fields for all cases.          |
+-----------------------------------------------------------------------+

Continued on next page

11\. VA Form 21-3537b: Field Examination Report, Continued

+------------+---------------------------------------------------------+
| ##### d. A | > For purposes of completion of VA Form 21-3537b,       |
| ttachments | > attachments include any material to be submitted with |
|            | > the report, except the request (VA Form 21-3537a).    |
|            | > This includes                                         |
|            |                                                         |
|            | -   sworn statements,                                   |
|            |                                                         |
|            | -   physical evidence (documents, etc.),                |
|            |                                                         |
|            | -   certificates of search, and                         |
|            |                                                         |
|            | -   memorandums of interviews.                          |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > List and label attachments in the sequence discussed in the         |
| > narrative report. Arrange the list by attachment letter, nature of  |
| > attachment, and identification, as follows:                         |
|                                                                       |
| A.  **Sworn statement of Nathan Cartwright, father-claimant.**        |
|                                                                       |
| B.  **Birth Certificate of Winston Cartwright, son.**                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Number pages of each sworn statement and/or other attachment for    |
| > identification purposes; e.g., **Attachment B, page 1**.            |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Insert all letters and numbers at the bottom of pages to maintain   |
| > uniformity throughout the report.                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Insert all evidence offered by a witness in support of his or her   |
| > sworn statement immediately following the statement.                |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > In cases requiring examination by multiple field examiners in the   |
| > same regional office, letter all attachments starting with **"A"**  |
| > for the first attachment and continuing consecutively to the last   |
| > attachment. This will facilitate a consecutive series within the    |
| > report. If you must refer the completed report for further field    |
| > examination, refer to the following chart for appropriate action:   |
+-----------------------------------------------------------------------+

Continued on next page

11\. VA Form 21-3537b: Field Examination Report, Continued

+-----------------------------------------------------------------------+
| > d\. Attachments (continued)                                         |
+-----------------------------------------------------------------------+

  ---------------------------------- ------------------------------------
  If a completed report of field     Take the following action ...
  examination, when submitted ...    

  must be returned to the same       make a supplemental report with
  office for further examination     attachments identified by the next
                                     continuing letters of the alphabet.
                                     Appropriately reference the previous
                                     report in the narrative portion of
                                     the supplemental report.

  must be referred or transferred to prepare a separate report. Identify
  another office for further field   attachments by the next continuing
  examination,                       letters of the alphabet.
  ---------------------------------- ------------------------------------

+------------+---------------------------------------------------------+
| ##### e    | > This section will include, but is not limited to      |
| . Comments |                                                         |
|            | -   a description of the context of interviews when     |
|            |     material facts were found and a memorandum of       |
|            |     interview was not prepared, and                     |
|            |                                                         |
|            | -   the field examiner's statement of his or her        |
|            |     personal evaluation of credibility of the           |
|            |     information elicited and the basis for the          |
|            |     impression.                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Sworn statements obtained during the course of a      |
| f. Sworn S | > field examination, must be handled appropriately to   |
| tatements  | > ensure they are admissible as evidence if needed.     |
|            | > These statements should generally be written and      |
|            | > signed by the witness.                                |
+------------+---------------------------------------------------------+

Continued on next page

11\. VA Form 21-3537b: Field Examination Report, Continued

+------------+---------------------------------------------------------+
| ##### g    | > Whenever possible, obtain a written statement from    |
| . Written  | > witnesses.                                            |
| Statements |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Conclude all written statements with:                               |
|                                                                       |
| 1.  **Witness's Concluding Statement**. The written statement will    |
|     > conclude with the witness's signed statement indicating his or  |
|     > her testimony is true and complete.                             |
|                                                                       |
| 2.  **Certification**. When a sworn or affirmed statement is typed or |
|     > handwritten, use the following form for the certification       |
|     > following the signature of the witness:                         |
|                                                                       |
| > > "Subscribed and sworn to (or affirmed) before me this \_\_\_\_    |
| > > day of \_\_\_\_\_\_\_\_\_\_, 20\_\_\_; and I hereby certify that  |
| > > the foregoing statement was read by (or read to, as the case may  |
| > > be) the witness before signing."                                  |
| >                                                                     |
| > > Below the certification, the FE will sign his or her name, title, |
| > > and authority, as follows:                                        |
| >                                                                     |
| > > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| >                                                                     |
| > > Signature, Field Examiner                                         |
| >                                                                     |
| > > Authority: VA Form 4505                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| 3.  **Corrections.** The witness must initial any corrections to a    |
|     > written (or affirmed) statement. Corrections must not alter the |
|     > testimony in any way except as intended by the witness.         |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > Refer to the following table for filing and retention |
| Filing and | > instructions:                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| If the request involves a ...    | Use the following instructions:   |
+----------------------------------+-----------------------------------+
| program field examination        | File the original 21-3537b in the |
|                                  | PGF and retain it for the life of |
|                                  | the file.                         |
+----------------------------------+-----------------------------------+
| non-program, or special field    | -   Refer the original report to  |
| examination                      |     the requesting element, and   |
|                                  |                                   |
|                                  | -   retain a copy in the F&FE     |
|                                  |     Activity correspondence or    |
|                                  |     VetsFile, as appropriate.     |
+----------------------------------+-----------------------------------+

#### 12. VA Form 21-4703: Fiduciary Agreement 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-4703 is used by the field examiner to      |
| a. What is | > obtain the fiduciary's agreement to serve as          |
|  this form | > fiduciary under the direction and supervision of the  |
|  used for? | > VA.                                                   |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | Prepare VA Form 21-4703 when you select any of the      |
| ## b. When | following fiduciary arrangements:                       |
|  should th |                                                         |
| is form be | -   Legal Custodian                                     |
|  prepared? |                                                         |
|            | -   Spouse Payee                                        |
|            |                                                         |
|            | -   Institutional Award                                 |
|            |                                                         |
|            | -   Custodian in Fact                                   |
|            |                                                         |
|            | -   Temporary Fiduciary                                 |
|            |                                                         |
|            | -   Superintendent of Indian Reservation                |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > This form is a carbon-pack. Once executed, retain the original for  |
| > filing in the PGF. Give the copy to the fiduciary.                  |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  --------------------- -------------------- -----------------------------
  Block# and Title      Is completed by ...  Who enters ...

  **1. ADDRESS OF VA    FE                   the complete mailing address
  OFFICE**                                   for the VA supervising office

  **2. VA CONTACT/      FE                   Self-explanatory.
  PHONE NUMBER**                             

  **3. NAME OF          FE                   the veteran's full name
  VETERAN**                                  

  **4. VA FILE NUMBER** FE                   Self-explanatory.

  **5. SOCIAL SECURITY  FE                   Self-explanatory.
  NUMBER**                                   

  **6A -- 6F. NAME(S)   FE                   the name(s) of all
  OF                                         beneficiaries covered by the
  BENE-FICIARY(IES)**                        agreement.
  --------------------- -------------------- -----------------------------

Continued on next page

12\. VA Form 21-4703: Fiduciary Agreement, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------+--------------------+-------------------------------+
| Block# and      | Is completed by    | Who enters ...                |
| Title           | ...                |                               |
+-----------------+--------------------+-------------------------------+
| **7. I, THE     |                    |                               |
| UNDERSIGNED     |                    |                               |
| FIDUCIARY,      |                    |                               |
| HEREBY AGREE TO |                    |                               |
| SERVE AS:**     |                    |                               |
+-----------------+--------------------+-------------------------------+
| **LEGAL         | FE                 | A checkmark if legal          |
| CUSTODIAN**     |                    | custodian is selected as the  |
|                 |                    | fiduciary arrangement.        |
|                 |                    |                               |
|                 |                    | Select this option for if the |
|                 |                    | fiduciary arrangement         |
|                 |                    | involves a                    |
|                 |                    |                               |
|                 |                    | -   legal custodian,          |
|                 |                    |                               |
|                 |                    | -   temporary fiduciary, or   |
|                 |                    |                               |
|                 |                    | -   the superintendent of an  |
|                 |                    |     Indian reservation.       |
+-----------------+--------------------+-------------------------------+
| **CUST          | FE                 | A checkmark if                |
| ODIAN-IN-FACT** |                    | custodian-in-fact is selected |
|                 |                    | as the fiduciary arrangement. |
+-----------------+--------------------+-------------------------------+
| **SPOUSE        | FE                 | A checkmark if spouse payee   |
| PAYEE**         |                    | is selected as the fiduciary  |
|                 |                    | arrangement. This payment     |
|                 |                    | arrangement is valid for      |
|                 |                    | veteran beneficiaries *only*. |
+-----------------+--------------------+-------------------------------+
| **INSTITUTIONAL | **FE**             | **A checkmark if              |
| PAYEES**        |                    | institutional payee is        |
|                 |                    | selected as the fiduciary     |
|                 |                    | arrangement. This payment     |
|                 |                    | arrangement is valid for      |
|                 |                    | veteran beneficiaries         |
|                 |                    | *only*.**                     |
+-----------------+--------------------+-------------------------------+
| **I AGREE TO    |                    |                               |
| SAVE THE        |                    |                               |
| FOLLOWING       |                    |                               |
| AMOUNTS:**      |                    |                               |
+-----------------+--------------------+-------------------------------+
| **8A. LUMP SUM  | FE                 | any amount from a lump sum    |
| AMOUNT**        |                    | award that the fiduciary is   |
|                 |                    | required to save.             |
+-----------------+--------------------+-------------------------------+
| **8B. MONTHLY   | FE                 | any amount from a             |
| AMOUNT**        |                    | beneficiary's monthly award   |
|                 |                    | that the fiduciary is         |
|                 |                    | required to save.             |
+-----------------+--------------------+-------------------------------+
| **8C. EFFECTIVE | FE                 | the effective date of the     |
| DATE**          |                    | requirement to save.          |
+-----------------+--------------------+-------------------------------+

Continued on next page

12\. VA Form 21-4703: Fiduciary Agreement, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------ -------------------- -------------------------------
  Block# and Title   Is completed by ...  Who enters ...

  **ACCOUNTING       FE                   A checkmark in the appropriate
  STATEMENT**                             block (i.e. "am," or "am not")
                                          to indicate if an accounting is
                                          required.

  **9A. SIGNATURE OF Fiduciary            Self-explanatory.
  FIDUCIARY**                             

  **9B. SOCIAL       Fiduciary or FE      Self-explanatory.
  SECURITY NUMBER OF                      
  FIDUCIARY**                             

  **9C. DATE         Fiduciary or FE      Self-explanatory.
  SIGNED**                                

  **9D. NAME OF      Fiduciary or FE      the typed or printed name of
  FIDUCIARY**                             the fiduciary.

  **9E. TITLE OF     Fiduciary or FE      Enter Legal Custodian, Spouse
  FIDUCIARY**                             Payee, Institutional Award,
                                          Custodian in Fact, Temporary
                                          Fiduciary, or Superintendent of
                                          Indian Reservation, as
                                          appropriate.

  **BACK OF FORM**   FE                   Although there are no required
                                          entries on the reverse of the
                                          21-4703, the FE must review all
                                          elements with the prospective
                                          fiduciary. It may be helpful to
                                          request the fiduciary initial
                                          each element as it is
                                          discussed.
  ------------------ -------------------- -------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d. R | > It is essential that you meet, face-to-face, with the |
| eview with | > prospective fiduciary to                              |
|  Fiduciary |                                                         |
|            | -   explain the provisions of this agreement, and       |
|            |                                                         |
|            | -   obtain the prospective fiduciary's signature        |
|            |     agreeing to serve.                                  |
+------------+---------------------------------------------------------+

Continued on next page

12\. VA Form 21-4703: Fiduciary Agreement, Continued

+------------+---------------------------------------------------------+
| ##### e.   | > Back-file the original VA Form 21-4703 on the left    |
| Filing and | > flap of the PGF. This form must remain back-filed for |
|  Retention | > the duration of the appointment of the fiduciary. If  |
|            | > a successor fiduciary is appointed, file the document |
|            | > down in the PGF and, if the successor fiduciary is a  |
|            | > federal fiduciary, back-file the new VA Form 21-4703. |
|            | > Retain all VA Forms 21-4703 for the life of the PGF.  |
+------------+---------------------------------------------------------+

#### 13. VA Form 21-4706: Court Appointed Fiduciary's Accounting 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-4706 is used for a court appointed         |
| a. What is | > fiduciary's periodic accounting. This form is         |
|  this form | > formatted on legal-size paper (8 ½ x 14) and is       |
|  used for? | > substantially the same as VA Form 21-4706c. Use the   |
|            | > format preferred by courts in your area.              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | Provide this form to a fiduciary that VA recognizes     |
|  When shou | that was appointed by a state court. This document must |
| ld you pro | be filed with the court of jurisdiction and be properly |
| vide this  | authenticated as a true copy of the document filed with |
| form to a  | the court.                                              |
| fiduciary? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note***: Use of this form is ***not*** mandatory. Some courts    |
| > require accountings to be completed on their forms. Accept a        |
| > court-appointed fiduciary's accounting in any format acceptable to  |
| > the court.                                                          |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The fiduciary (or his or her attorney) generally      |
| ### c. Com | > completes this form. Because this is a court          |
| pletion in | > document, VA cannot mandate how the fiduciary must    |
| structions | > complete it. The form consists of four pages.         |
|            | > Following are general guidelines for completion.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page one is divided into three sections.              |
|  d. Page 1 |                                                         |
|            | -   The top third of page one consists of case          |
|            |     identification.                                     |
|            |                                                         |
|            | -   The middle third consists of                        |
|            |                                                         |
|            |     \- the beneficiary's name and address,              |
|            |                                                         |
|            |     \- accounting period, and                           |
|            |                                                         |
|            |     \- surety bond information.                         |
|            |                                                         |
|            | -   The bottom third is used for itemizing income       |
|            |     received by the fiduciary on behalf of the          |
|            |     beneficiary.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page two is divided into three sections.              |
|  e. Page 2 |                                                         |
|            | -   The top half of page two is used for itemizing      |
|            |     payments made from the beneficiary's funds, by the  |
|            |     fiduciary and on behalf of the beneficiary.         |
+------------+---------------------------------------------------------+

Continued on next page

13\. VA Form 21-4706: Court Appointed Fiduciary's Accounting, Continued

+------------+---------------------------------------------------------+
| e\. Page 2 | -   The bottom half is divided into two sections.       |
| (          |                                                         |
| continued) |     \- The first, Summary, consists of a recapitulation |
|            |     of estate activity.                                 |
|            |                                                         |
|            |     \- The financial institution where estate funds are |
|            |     held on deposit completes the second section,       |
|            |     Certification of Balance on Deposit. This portion   |
|            |     requires entry of account identification (i.e.,     |
|            |     identity of financial institution, account numbers, |
|            |     balances, interest earned, and signature of         |
|            |     certifying official, and seal or stamp of the       |
|            |     financial institution).                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page three is divided into two sections.              |
|  f. Page 3 |                                                         |
|            | -   The fiduciary completes the top section,            |
|            |     Certification of Investments, listing all           |
|            |     securities (i.e., savings bonds, U.S. Treasury      |
|            |     Notes, money market accounts, etc.). The fiduciary  |
|            |     then presents the accounting, along with the        |
|            |     securities, to a certifying official. The           |
|            |     certifying official completes the center, or        |
|            |     "certification" section. The certifying official    |
|            |     will generally be a bank official or the clerk of   |
|            |     the court.                                          |
|            |                                                         |
|            | -   The fiduciary signs the bottom section, attesting   |
|            |     to the report, before a notary public who affixes   |
|            |     his or her signature and notary stamp.              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page four includes required Privacy Act and           |
|  g. Page 4 | > Respondent Burden information, along with case        |
|            | > identification, filing information, and a record of   |
|            | > the court's approval.                                 |
|            |                                                         |
|            | -   The fiduciary completes the case identification     |
|            |     portion.                                            |
|            |                                                         |
|            | -   Filing and court approval information will be       |
|            |     completed by the court.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > When the fiduciary files his or her accounting on VA  |
| Filing and | > Form 21-4706, you must ensure that you receive a copy |
|  Retention | > of the document that has been certified by the        |
|            | > custodian of the record. As accountings can contain   |
|            | > numerous pages, particularly if the fiduciary is a    |
|            | > corporate fiduciary, it is suggested that accountings |
|            | > be filed in the center flap to minimize damage to the |
|            | > older during routine use. Whichever flap is used      |
|            | > locally, however, ensure your format is uniform for   |
|            | > all court appointed fiduciary files.                  |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Retain the current accounting and prior two accountings. Dispose of |
| > older documents in accordance with RCS VB-1, Part I. It is not      |
| > necessary to retain all older accountings as, should you later have |
| > need for an older document, you will be able to obtain it from the  |
| > court.                                                              |
+-----------------------------------------------------------------------+

#### 14. VA Form 21-4706b: Federal Fiduciary's Account 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-4706b is used for a federal fiduciary's    |
| a. What is | > periodic accounting.                                  |
|  this form |                                                         |
|  used for? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | Provide this form to a federal fiduciary when a         |
|  When shou | required accounting becomes due. (Use will be rare in   |
| ld you pro | spouse payee situations.) The fiduciary must furnish    |
| vide this  | the original, properly signed, copy of this document to |
| form to a  | VA for review.                                          |
| fiduciary? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Use of this form is mandatory unless the federal        |
| > fiduciary is also court appointed. Although VA may accept a copy of |
| > the accounting filed with the court, this situation should be rare. |
| > In instances where VA requires an accounting from a fiduciary that  |
| > is also court-appointed, it is generally advisable to recognize the |
| > court appointment.                                                  |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ----------------- --------------- --------------------------------------
  Block# and Title  Is completed by Who enters ...
  ...               ...             

  **FROM**          LIE or          the name and mailing address of the
                    Fiduciary       fiduciary.

  **TO**            LIE or          the office designation (i.e. VARO,
                    Fiduciary       etc.) and mailing address for the
                                    Fiduciary Activity that supervises the
                                    fiduciary.

  **NAME OF         LIE or          Self-explanatory.
  VETERAN**         Fiduciary       

  **NAME OF         LIE or          Self-explanatory. Required only if the
  BENEFICIARY**     Fiduciary       beneficiary is not the veteran.

  **VA FILE         LIE or          Self-explanatory.
  NUMBER**          Fiduciary       

  **SECTION I --                    
  STATEMENT OF                      
  ACCOUNT**                         

  **ACCOUNTING                      
  PERIOD:**                         

  **FROM**          Fiduciary       the beginning date of the accounting
                                    period.

  **TO**            Fiduciary       the end date of the accounting period.
  ----------------- --------------- --------------------------------------

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **1. MONEY     |              |                                      |
| RECEIVED**     |              |                                      |
+----------------+--------------+--------------------------------------+
| **1A. TOTAL    | Fiduciary    | the estate balance as of the         |
| ESTATE AT      |              | beginning date of the accounting     |
| BEGINNING OF   |              | period. If this is an initial        |
| PERIOD**       |              | accounting, this should be the       |
|                |              | balance certified by the field       |
|                |              | examiner at the time of the initial  |
|                |              | appointment.                         |
|                |              |                                      |
|                |              | If it is a subsequent accounting, it |
|                |              | should be the ending balance from    |
|                |              | the prior accounting.                |
+----------------+--------------+--------------------------------------+
| **1B. AMOUNT   | Fiduciary    | the total of benefits paid to the    |
| RECEIVED FROM  |              | fiduciary, by VA, during the         |
| VA**           |              | accounting period. The fiduciary     |
|                |              | should breakdown this figure by      |
|                |              | monthly amounts and the number of    |
|                |              | months at each rate of payment.      |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **1C. AMOUNT   | Fiduciary    | the total of benefits paid to the    |
| RECEIVED FROM  |              | fiduciary, by Social Security,       |
| SOCIAL         |              | during the accounting period. The    |
| SECURITY**     |              | fiduciary should breakdown this      |
|                |              | figure by monthly amounts and the    |
|                |              | number of months at each rate of     |
|                |              | payment.                             |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **1D. INTEREST | Fiduciary    | the total interest paid to the       |
| EARNED ON      |              | fiduciary on all funds on deposit    |
| DEPOSITS**     |              | belonging to the beneficiary and     |
|                |              | managed by the fiduciary.            |
+----------------+--------------+--------------------------------------+

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **1E -- 1H.    | Fiduciary    | the fiduciary should identify the    |
| AMOUNT         |              | source and amount of any other funds |
| RECEIVED FROM  |              | received on behalf of the            |
| OTHER          |              | beneficiary.                         |
| SOURCES**      |              |                                      |
|                |              | The fiduciary should enter only      |
|                |              | actual income, exclusive of any      |
|                |              | asset transfers (i.e., negotiation   |
|                |              | of savings bond, redemption of CD,   |
|                |              | etc.).                               |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **1I. TOTAL    | Fiduciary    | the total funds available. This      |
| RECEIVED**     |              | figure includes the beginning estate |
|                |              | plus all income received by the      |
|                |              | fiduciary for the beneficiary during |
|                |              | the accounting period.               |
+----------------+--------------+--------------------------------------+
| **2. MONEY     |              |                                      |
| SPENT**        |              |                                      |
+----------------+--------------+--------------------------------------+
| **2A. ROOM AND | Fiduciary    | the total spent for housing for the  |
| BOARD/ RENT**  |              | beneficiary during the accounting    |
|                |              | period. The fiduciary should         |
|                |              | breakdown this figure by monthly     |
|                |              | amounts and the number of months at  |
|                |              | each rate of payment.                |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **2B.          | Fiduciary    | the total spent on clothing for the  |
| CLOTHING**     |              | beneficiary, during the accounting   |
|                |              | period. The fiduciary should         |
|                |              | breakdown this figure as per the     |
|                |              | agreement with the field examiner.   |
+----------------+--------------+--------------------------------------+

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **2C.          | Fiduciary    | the total spent on the beneficiary's |
| EN             |              | entertainment needs, during the      |
| TERTAIN-MENT** |              | accounting period. The fiduciary     |
|                |              | should breakdown this figure as per  |
|                |              | the agreement with the field         |
|                |              | examiner.                            |
+----------------+--------------+--------------------------------------+
| **2D. PERSONAL | Fiduciary    | the total funds given to the         |
| USE**          |              | beneficiary for personal and         |
|                |              | incidental needs, during the         |
|                |              | accounting period. The fiduciary     |
|                |              | should breakdown this figure by      |
|                |              | monthly amounts and the number of    |
|                |              | months at each rate of payment.      |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **2E.          | Fiduciary    | the total of support payments made   |
| DEPENDENT      |              | by the fiduciary for care of the     |
| SUPPORT**      |              | beneficiary's VA recognized          |
|                |              | dependents not in the beneficiary's  |
|                |              | household, during the accounting     |
|                |              | period. The fiduciary should         |
|                |              | breakdown this figure by monthly     |
|                |              | amounts and the number of months at  |
|                |              | each rate of payment.                |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **2F.          | Fiduciary    | the amount of any fiduciary fee      |
| FIDUCIARY FEE  |              | (commission) charged by the          |
| IF APPROVED BY |              | fiduciary during the accounting      |
| VA**           |              | period.                              |
+----------------+--------------+--------------------------------------+

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **2G -- 2L.    | Fiduciary    | any expenses not entered in items 2A |
| OTHER          |              | through 2F. The fiduciary should     |
| (Specify)**    |              | identify any other expenses by the   |
|                |              | nature of the expense and the total  |
|                |              | amount spent.                        |
|                |              |                                      |
|                |              | The fiduciary should enter only      |
|                |              | actual expenses, exclusive of any    |
|                |              | asset transfers (i.e., purchase of   |
|                |              | savings bond, CD, etc.).             |
|                |              |                                      |
|                |              | If additional space is needed, this  |
|                |              | information can be continued in Item |
|                |              | 6, Remarks.                          |
+----------------+--------------+--------------------------------------+
| **2M. TOTAL    | Fiduciary    | the total of all expenditures        |
| SPENT**        |              | itemized in blocks 2A through 2L.    |
|                |              | Enter even if amount is zero.        |
+----------------+--------------+--------------------------------------+
| **4. ASSETS AT |              |                                      |
| END OF         |              |                                      |
| PERIOD**       |              |                                      |
+----------------+--------------+--------------------------------------+
| **4A. CASH ON  | Fiduciary    | Self-explanatory. The fiduciary      |
| HAND**         |              | should list only actual "cash."      |
+----------------+--------------+--------------------------------------+
| **4B. AMOUNT   | Fiduciary    | Self-explanatory. If the fiduciary   |
| IN CHECKING    |              | maintains two or more checking       |
| ACCOUNT**      |              | accounts, s/he should enter the      |
|                |              | total of funds in all accounts.      |
+----------------+--------------+--------------------------------------+
| **4C. AMOUNT   | Fiduciary    | Self-explanatory. If the fiduciary   |
| IN SAVINGS     |              | maintains two or more savings        |
| ACCOUNT**      |              | accounts, s/he should enter the      |
|                |              | total of funds in all accounts.      |
+----------------+--------------+--------------------------------------+
| **4D. TOTAL    | Fiduciary    | Self-explanatory.                    |
| PURCHASE PRICE |              |                                      |
| OF SAVINGS     |              |                                      |
| BONDS LISTED   |              |                                      |
| ON REVERSE**   |              |                                      |
+----------------+--------------+--------------------------------------+

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **4D(1). IF    | Fiduciary    | a response of "yes" or "no" to this  |
| PURCHASE PRICE |              | question. If the fiduciary responds  |
| OF SAVINGS     |              | "yes," you must obtain a copy of any |
| BONDS CHANGED  |              | newly purchased savings bonds.       |
| FROM THE LAST  |              |                                      |
| ACCOUNTING     |              |                                      |
| PERIOD, WERE   |              |                                      |
| ADDITIONAL     |              |                                      |
| BONDS          |              |                                      |
| PURCHASED?**   |              |                                      |
+----------------+--------------+--------------------------------------+
| **4D(2). WERE  | Fiduciary    | a response of "yes" or "no" to this  |
| SAVINGS BONDS  |              | question. If the fiduciary responds  |
| CASHED DURING  |              | "yes," s/he should also enter the    |
| THE PERIOD?**  |              | amount of interest paid as a         |
|                |              | receipt.                             |
+----------------+--------------+--------------------------------------+
| **5. TOTAL     | Fiduciary    | Self-explanatory.                    |
| ASSETS**       |              |                                      |
+----------------+--------------+--------------------------------------+
| **6. REMARKS** | Fiduciary    | continuation of any income or estate |
|                |              | entries, as well as any additional   |
|                |              | information needed to clarify        |
|                |              | accounting entries.                  |
|                |              |                                      |
|                |              | Remarks block is continued on the    |
|                |              | back of the form.                    |
+----------------+--------------+--------------------------------------+
| **7. DATE**    | Fiduciary    | the date s/he signs the accounting   |
|                |              | document.                            |
+----------------+--------------+--------------------------------------+
| **8.           | Fiduciary    | his or her signature and title.      |
| SUBMIT-TED     |              |                                      |
| BY**           |              |                                      |
+----------------+--------------+--------------------------------------+
| **9. DATE      | LIE          | the date s/he finally approves the   |
| APPROVED**     |              | accounting document.                 |
+----------------+--------------+--------------------------------------+
| **10. APPROVED | LIE          | his or her signature and title.      |
| BY**           |              |                                      |
+----------------+--------------+--------------------------------------+

Continued on next page

14\. VA Form 21-4706b: Federal Fiduciary's Account, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+----------------+--------------+--------------------------------------+
| Block# and     | Is completed | Who enters ...                       |
| Title ...      | by ...       |                                      |
+----------------+--------------+--------------------------------------+
| **SECTION II   |              |                                      |
| --             |              |                                      |
| CERTIFICATION  |              |                                      |
| OF U.S.        |              |                                      |
| SAVINGS        |              |                                      |
| BONDS**        |              |                                      |
|                |              |                                      |
| **(**Space is  |              |                                      |
| provided for   |              |                                      |
| the fiduciary  |              |                                      |
| to list 20     |              |                                      |
| savings bonds. |              |                                      |
| If additional  |              |                                      |
| space is       |              |                                      |
| needed, this   |              |                                      |
| information    |              |                                      |
| can be         |              |                                      |
| continued in   |              |                                      |
| Item 6,        |              |                                      |
| Remarks.)      |              |                                      |
+----------------+--------------+--------------------------------------+
| **SERIAL       | Fiduciary    | the individual serial number of each |
| NUMBER**       |              | savings bond.                        |
+----------------+--------------+--------------------------------------+
| **DATE OF      | Fiduciary    | the date of purchase for each        |
| PURCHASE**     |              | savings bond.                        |
+----------------+--------------+--------------------------------------+
| **PURCHASE     | Fiduciary    | the purchase price of each savings   |
| PRICE**        |              | bond.                                |
+----------------+--------------+--------------------------------------+
| **SIGNATURE OF | Fiduciary    | his or her signature.                |
| FIDUCIARY**    |              |                                      |
+----------------+--------------+--------------------------------------+
| **DATE**       | Fiduciary    | the date s/he signs the savings bond |
|                |              | certification.                       |
+----------------+--------------+--------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > File the original VA Form 21-4706b on the left flap   |
| Filing and | > of the PGF. (If you use a green three-flap folder for |
|  retention | > federal fiduciaries who account, file VA Form         |
|            | > 21-4706b on the center flap.)                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Retain the current and all prior accounting accountings for the     |
| > life of the PGF.                                                    |
+-----------------------------------------------------------------------+

#### 15. VA Form 21-4706c: Court Appointed Fiduciary's Accounting 

+------------+---------------------------------------------------------+
| #####      | > VA Form 21-4706c is used for a court appointed        |
| a. What is | > fiduciary's periodic accounting. This form is         |
|  this form | > formatted on standard 8 ½ x 11 paper and is           |
|  used for? | > substantially the same as VA Form 21-4706. Use the    |
|            | > format preferred by courts in your area.              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | Provide this form to a fiduciary VA recognizes that was |
|  When shou | appointed by a state court. This document must be filed |
| ld this fo | with the court of jurisdiction and be properly          |
| rm be prov | authenticated as a true copy of the document filed with |
| ided to a  | the court.                                              |
| fiduciary? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note***: Use of this form is ***not*** mandatory; accept a       |
| > court-appointed fiduciary's accounting in any format acceptable to  |
| > the court.                                                          |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The fiduciary (or his or her attorney) generally      |
| ### c. Com | > completes this form. Because this is a court          |
| pletion in | > document, VA cannot mandate how the fiduciary must    |
| structions | > complete it. The form consists of four pages.         |
|            | > Following are general guidelines for completion.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page one is divided into two sections.                |
|  d. Page 1 |                                                         |
|            | -   The top third of the page consists of               |
|            |                                                         |
|            |     \- VA case identification, followed by              |
|            |                                                         |
|            |     \- court identification.                            |
|            |                                                         |
|            | -   The fiduciary itemizes income received by the       |
|            |     fiduciary on behalf of the beneficiary on the       |
|            |     bottom two-thirds of page two.                      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > The fiduciary itemizes payments made on behalf of the |
|  e. Page 2 | > beneficiary, from estate funds, on page two.          |
+------------+---------------------------------------------------------+

Continued on next page

15\. VA Form 21-4706c: Court Appointed Fiduciary's Accounting, Continued

+------------+---------------------------------------------------------+
| #####      | > Page three is divided into three sections.            |
|  f. Page 3 |                                                         |
|            | -   The fiduciary enters his or her recapitulation of   |
|            |     estate activity in the top third.                   |
|            |                                                         |
|            | -   The middle third requires the fiduciary attest to   |
|            |     the truthfulness and completeness of the document   |
|            |     by entering his or her signature before a           |
|            |     certifying official, generally a notary public.     |
|            |                                                         |
|            | -   The bottom third of page three is completed by the  |
|            |     financial institution where funds are held on       |
|            |     deposit. This section is used for certifying the    |
|            |     existence of funds remaining in the estate as of    |
|            |     the end date of the accounting period. ***Note:***  |
|            |     Although use of this section is acceptable, use of  |
|            |     VA Form 21-4718a is preferred as it provides for    |
|            |     the fiduciary's signature authorizing independent   |
|            |     verification of assets.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Page four of the VA Form 21-4706c provides for        |
|  g. Page 4 | > certification of securities. The fiduciary completes  |
|            | > the top section, listing all securities (i.e.,        |
|            | > savings bonds, U.S. Treasury Notes, money market      |
|            | > accounts, etc.). The fiduciary then presents the      |
|            | > accounting, along with the securities, to a           |
|            | > certifying official. The certify in official may be   |
|            | > the judge or clerk of court, an official of the       |
|            | > safety deposit company or bank where securities are   |
|            | > held, or an authorized official or agent of the       |
|            | > company that is surety on the bond.                   |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The certifying official completes the bottom section, attesting to  |
| > the existence of the documents by entering his or her signature,    |
| > title, address, and date of certification.                          |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > When the fiduciary files his or her accounting on VA  |
| Filing and | > Form 21-4706, you must ensure that you receive a copy |
|  Retention | > of the document that has been certified by the        |
|            | > custodian of the record. As accountings can contain   |
|            | > numerous pages, particularly if the fiduciary is a    |
|            | > corporate fiduciary, it is suggested that accountings |
|            | > be filed in the center flap to minimize damage to the |
|            | > older during routine use. Whichever flap is used      |
|            | > locally, however, ensure your format is uniform for   |
|            | > all court appointed fiduciary files.                  |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Retain the current accounting and prior two accountings. Dispose of |
| > older documents in accordance with RCS VB-1, Part I. It is not      |
| > necessary to retain all older accountings as, should you later have |
| > need for an older document, you will be able to obtain it from the  |
| > court.                                                              |
+-----------------------------------------------------------------------+

#### 16. VA Form 21-4707: Estate Summary 

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-4707 to summarize frequently needed    |
| a. What is | > information concerning a beneficiary and his or her   |
|  this form | > fiduciary, recurrent income and allowance data,       |
|  used for? | > protection, estate and miscellaneous case-specific    |
|            | > data.                                                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > The LIE generally prepares this form when all of the  |
| ## b. When | > following apply:                                      |
|  should th |                                                         |
| is form be | -   s/he establishes or updates a PGF for an            |
|  prepared? |     incompetent beneficiary, when                       |
|            |                                                         |
|            | -   a fiduciary (or successor fiduciary) is certified,  |
|            |     and                                                 |
|            |                                                         |
|            | -   the fiduciary is required to furnish periodic       |
|            |     accountings.                                        |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > To ensure that this document is useful, it is essential that        |
| > fiduciary personnel continuously update it as information changes.  |
| > Although initially prepared by the LIE in most cases, all fiduciary |
| > personnel are responsible to update the Estate Summary whenever     |
| > they review a PGF and note information has changed.                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > A new VA Form 21-4707 must be prepared when information from seven  |
| > accounting periods have ben entered in Block 11, Estate Data.       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** This is form is used exclusively within the Fiduciary   |
| > activity.                                                           |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **1. FIRST-MIDDLE-LAST NAME OF Self-Explanatory.
  VETERAN**                      

  **2. SOCIAL SECURITY NUMBER**  Enter the veteran's Social Security
                                 number.

  **3. VA FILE NUMBER**          Self-Explanatory.

  **4. WARD**                    

  **4A. NAME AND ADDRESS OF      Self-Explanatory.
  WARD**                         

  **4B. TELEPHONE NO.**          Self-Explanatory.

  **4C. DATE OF BIRTH**          Self-Explanatory.

  **4D. WARD IS:**               Enter a checkmark to designate the
                                 "Type" of beneficiary. Options include
                                 "veteran," "minor," and "other adult."
  ------------------------------ ----------------------------------------

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Required Information                   |
+-----------------------------+----------------------------------------+
| **4E. COMPETENCY STATUS**   | Enter a checkmark to designate the     |
|                             | basis for VA supervision. The VA must  |
|                             | pay benefits directly to the           |
|                             | beneficiary unless there is either a   |
|                             | rating of incompetence or a            |
|                             | determination of legal disability by a |
|                             | court. The only exception is when a    |
|                             | temporary fiduciary is appointed under |
|                             | authority of 38 U.S.C. 5507.           |
|                             |                                        |
|                             | Check "under legal disability by state |
|                             | law" if the beneficiary is adjudged by |
|                             | the court as incompetent or is         |
|                             | otherwise under a legal disability.    |
|                             |                                        |
|                             | Check "Rated incompetent by VA" if the |
|                             | beneficiary has ben rated incompetent  |
|                             | by VA.                                 |
|                             |                                        |
|                             | Check both options if the beneficiary  |
|                             | is under a legal disability by state   |
|                             | law and also rated incompetent by VA.  |
+-----------------------------+----------------------------------------+
| **4F. EFFECTIVE DATE**      | Enter the effective date of the        |
|                             | current legal disability, or the VA    |
|                             | rating of incompetency, as             |
|                             | appropriate.                           |
|                             |                                        |
|                             | Complete both blocks if the            |
|                             | beneficiary is under a legal           |
|                             | disability by state law and also rated |
|                             | incompetent by VA.                     |
+-----------------------------+----------------------------------------+
| **5. FIDUCIARY**            |                                        |
+-----------------------------+----------------------------------------+
| **5A. NAME AND ADDRESS OF   | Self-Explanatory.                      |
| FIDUCIARY**                 |                                        |
+-----------------------------+----------------------------------------+
| **5B. TELEPHONE NO.**       | Self-Explanatory.                      |
+-----------------------------+----------------------------------------+
| **5C. DATE OF APPOINTMENT** | Enter the date the current fiduciary   |
|                             | was appointed. This will be either the |
|                             | date of court appointment, or the date |
|                             | VA certified the fiduciary.            |
+-----------------------------+----------------------------------------+
| **5D. FIDUCIARY IS:**       | Check the appropriate block to         |
|                             | indicate the payee arrangement.        |
|                             | Options include legal custodian (to    |
|                             | include temporary fiduciary),          |
|                             | spouse/payee, institutional payee, and |
|                             | court appointed.                       |
+-----------------------------+----------------------------------------+

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **5E. RELATIONSHIP TO WARD**   Enter the fiduciary's relationship to
                                 the beneficiary or "none," as
                                 appropriate.

  **5F. COURT OF JURISDICTION**  Enter the court of jurisdiction for
                                 court-appointed fiduciaries. Required if
                                 the fiduciary is court-appointed.

  **5G. COURT FILE NO.**         Enter the number used by a court to
                                 identify the particular case, if
                                 applicable. Required if the fiduciary is
                                 court-appointed.

  **6. VA INCOME**               

  **6A. MONTHLY PAYMENT**        Enter the monthly payment amount for any
                                 VA benefit the beneficiary receives, in
                                 the appropriate block.

  **6B. EFFECTIVE DATE**         Enter the effective date(s) for the
                                 dollar amount(s) entered under "monthly
                                 payment" in block 6A.

  **7. OTHER INCOME**            

  **7A. MONTHLY PAYMENT**        Enter the monthly payment amount for any
                                 "other monthly" benefit the beneficiary
                                 receives, in the appropriate block. If
                                 you enter data in the "other" block,
                                 specify the income source.

  **7B. EFFECTIVE DATE**         Enter the effective date(s) for the
                                 dollar amount(s) entered under "monthly
                                 payment" in block 7A.

  **8. NAME OF PAYEE FOR "OTHER  Enter the name(s) of any person(s) who
  PAYMENTS" IF NOT VA            receives(s) payment of the other-than-VA
  FIDUCIARY**                    benefits identified in block 7A.

  **9. ALLOWANCES AUTHORIZED**   

  **9A. WARD**                   Use these fields to document all
                                 authorized allowances for the care and
                                 support of the beneficiary.

  **BY**                         Specify whether the beneficiary's
                                 allowance is authorized by court order
                                 or VA.

  **DATE**                       Enter the date of the allowance
                                 authorization.
  ------------------------------ ----------------------------------------

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Required Information                   |
+-----------------------------+----------------------------------------+
| **MONTHLY**                 | Enter the amount of the authorized     |
|                             | allowance if paid monthly.             |
+-----------------------------+----------------------------------------+
| **OTHER**                   | Enter the amount of the authorized     |
|                             | allowance if paid other than monthly.  |
+-----------------------------+----------------------------------------+
| **9B. DEPENDENT**           | Use these fields to document all       |
|                             | authorized allowances for the care and |
|                             | support of the beneficiary's           |
|                             | recognized dependents.                 |
+-----------------------------+----------------------------------------+
| **BY**                      | Specify whether the dependent          |
|                             | allowance is authorized by court order |
|                             | or by VA.                              |
+-----------------------------+----------------------------------------+
| **DATE**                    | Enter the date of the allowance        |
|                             | authorization.                         |
+-----------------------------+----------------------------------------+
| **MONTHLY**                 | Enter the amount of the authorized     |
|                             | allowance if paid monthly.             |
+-----------------------------+----------------------------------------+
| **OTHER**                   | Enter the amount of the authorized     |
|                             | allowance if paid other than monthly.  |
+-----------------------------+----------------------------------------+
| **10. SURETY BOND**         | Use these fields to document any       |
|                             | existing surety bond protection.       |
+-----------------------------+----------------------------------------+
| **CORP. OR PERSONAL**       | Check "corp." when a corporation that  |
|                             | issues surety bonds in the state has   |
|                             | issued the bond. This may be a bonding |
|                             | company, a bank, or other              |
|                             | organization.                          |
|                             |                                        |
|                             | Check "personal" when the fiduciary    |
|                             | has used personal sureties to provide  |
|                             | a bond. For example, the fiduciary may |
|                             | have used his or her personal property |
|                             | composed of land or other valuables as |
|                             | "insurance" that the beneficiary's     |
|                             | estate funds would not be embezzled or |
|                             | misused.                               |
+-----------------------------+----------------------------------------+
| **DATE POSTED OR**          | Initially, enter the date the bond was |
|                             | originally posted. Thereafter, enter   |
| **CHANGED**                 | the date the bond is increased or      |
|                             | decreased.                             |
+-----------------------------+----------------------------------------+
| **TOTAL AMOUNT**            | Initially, enter the amount of the     |
|                             | bond originally posted. Thereafter,    |
|                             | enter the new value if the bond is     |
|                             | increased or decreased.                |
+-----------------------------+----------------------------------------+

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **11. ESTATE DATA**            

  **11A. PERSONAL ESTATE**       Whenever possible, list only VA funds
                                 received, expended, or invested on
                                 behalf of the beneficiary during the
                                 account period and the cash balance
                                 which was derived from VA funds at the
                                 end of the account period. When income
                                 from all sources is commingled and VA
                                 funds are not identifiable, list the
                                 total dollar amounts from all sources.

  **ACCOUNT PERIOD**             Enter the ***exact*** period covered by
                                 the accounting (e.g., 3/10/06 -- 3/9/07,
                                 vs. 3/06 -- 3/07 or 2006 -- 2007).

  **RECEIPTS**                   Enter the dollar amount of VA funds
                                 received by the beneficiary.

  **EXPENDITURES**               Enter the total dollar amount of VA
                                 funds expended on behalf of the
                                 beneficiary. In the absence of factual
                                 evidence, presume VA is spent before
                                 other source funds.

  **INVESTMENTS**                Enter the total amount of the
                                 beneficiary's VA estate that was
                                 invested on behalf of the beneficiary.

  **CASH BALANCE**               Enter the total dollar amount of the
                                 beneficiary's VA estate that is in cash
                                 at the end of the accounting period.
                                 Cash includes funds on hand and funds in
                                 checking accounts or Negotiable Order of
                                 Withdrawal (NOW) accounts or accounts of
                                 a similar type.
  ------------------------------ ----------------------------------------

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------+----------------------------------------+
| Block# and Title            | Required Information                   |
+-----------------------------+----------------------------------------+
| **NET ESTATE --**           | Enter the net worth of the estate at   |
|                             | the end of the accounting period by a  |
| **VA/OTHER**                | breakdown of "VA" and "Other" funds.   |
|                             | In commingled estates, presume that VA |
|                             | funds received during the accounting   |
|                             | period were used to meet the           |
|                             | beneficiary's living expenses before   |
|                             | any other funds received, if there is  |
|                             | no factual evidence to the contrary.   |
|                             | Divide administrative expenses         |
|                             | proportionately between "VA" and       |
|                             | "Other" source funds.                  |
+-----------------------------+----------------------------------------+
| **11B. REAL ESTATE**        |                                        |
+-----------------------------+----------------------------------------+
| **VALUE**                   | Enter the value of each piece of real  |
|                             | property fully or partially owned by   |
|                             | the beneficiary. This information may  |
|                             | be obtained from court documents or    |
|                             | field examination reports.             |
|                             |                                        |
|                             | If the beneficiary does not own real   |
|                             | estate, enter "none."                  |
+-----------------------------+----------------------------------------+
| **DATE ESTABLISHED**        | Enter the date the property value was  |
|                             | established.                           |
+-----------------------------+----------------------------------------+
| **RECORDED**                | Enter the location, to include the     |
|                             | book, page, map, etc. where the        |
|                             | property deed was recorded.            |
+-----------------------------+----------------------------------------+
| **AT**                      | Indicate the property address and      |
|                             | specify if the property is used as the |
|                             | veteran's domicile.                    |
+-----------------------------+----------------------------------------+
| **12. BENEFIT PAYMENT       |                                        |
| ACTIONS** -- Document any   |                                        |
| suspension of VA benefits.  |                                        |
| When fiduciary program      |                                        |
| personnel request the       |                                        |
| suspension, initiate        |                                        |
| control to ensure all       |                                        |
| actions are timely and      |                                        |
| accurate. The FBS "MiscDue" |                                        |
| diary is suggested,         |                                        |
| however, the form of        |                                        |
| control is at local         |                                        |
| discretion.                 |                                        |
+-----------------------------+----------------------------------------+
| **DATE SUSPENSION           | Enter the date the suspension action   |
| EFFECTIVE**                 | became effective.                      |
+-----------------------------+----------------------------------------+
| **REASON FOR SUSPENSION**   | Enter the reason for the suspension.   |
+-----------------------------+----------------------------------------+
| **DATE RESUMPTION           | Enter the date payments were resumed.  |
| EFFECTIVE**                 |                                        |
+-----------------------------+----------------------------------------+

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **13. VETERAN WARDS ONLY**     

  **13A. RECORD OF PUBLIC        Entries in these fields should be made
  INSTITUTIONALIZATIONS**        only when the veteran is without spouse
                                 or dependent child. Record any
                                 institutionalization, hospitalization,
                                 or domicile by the United States or any
                                 political subdivision thereof, whether
                                 with or without charge. Include
                                 incarceration in penal institutions.

  **DATE ENTERED**               Enter the date of institutionalization.

  **NAME OF INSTITUTION**        Enter the name of the institution.

  **DATE RELEASED**              Enter the date of release, if
                                 applicable.

  **13B. CHILDREN**              

  **NAME**                       List the names of the veteran's
                                 dependent children.

  **BIRTH DATE**                 Enter the birth date for each dependent
                                 child.

  **13C. MARRIED?**              Check the appropriate block to indicate
                                 if the beneficiary is married. Required
                                 for veteran beneficiaries.

  **13D. VA LIFE INSURANCE**     Record the veteran's VA life insurance
                                 status.

  **IN EFFECT**                  Enter "yes" or "no" to indicate if the
                                 veteran has VA life insurance in effect.
                                 Required for veteran beneficiaries.

  **POLICY NO.**                 Enter the policy number for active
                                 policies.

  **AMOUNT**                     Enter the amount of insurance for active
                                 policies.

  **ON WAIVER**                  Enter "yes" or "no" to indicate whether
                                 premiums are on waiver for active
                                 policies.

  **INELIGIBLE**                 Check this block if the veteran is not
                                 eligible for VA life insurance.
  ------------------------------ ----------------------------------------

Continued on next page

16\. VA Form 21-4707: Estate Summary, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Complete all applicable blocks. Enter all information in ink except:  |
|                                                                       |
| -   Address blocks,                                                   |
|                                                                       |
| -   Telephone numbers, and                                            |
|                                                                       |
| -   Monthly payments.                                                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > As this information changes frequently, it is acceptable to         |
| > complete these blocks in pencil.                                    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Insert a new VA Form 21-4707 whenever a successor fiduciary is      |
| > certified.                                                          |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > Refer to the following table for filing instructions. |
| Filing and |                                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

  --------------------------------- -------------------------------------
  If the PGF is a ...               File VA Form 21-4707 ...

  green three-flap folder           on the top of an appropriately
                                    designated flap

  a Kraft folder                    on the top of the left flap.
  --------------------------------- -------------------------------------

+-----------------------------------------------------------------------+
| > Retain VA Forms 21-4707 for the life of the PGF.                    |
+-----------------------------------------------------------------------+

#### 17. VA Form 21-4709: Certificate as to Assets 

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-4709 to verify stocks, bonds and other |
| a. What is | > funds held by the fiduciary at the end of an          |
|  this form | > accounting period.                                    |
|  used for? |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Provide this form when a fiduciary, recognized by VA, |
| ## b. When | > reports accumulated funds held in stocks, bonds and   |
|  should th | > other securities at the end of an accounting period.  |
| is form be | > Court-appointed fiduciaries may report in another     |
|  prepared? | > appropriate format as acceptable to the court.        |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Although a federal fiduciary cannot legally invest      |
| > VA-derived funds in such securities, s/he may report purchase of    |
| > securities with "other source" funds.                               |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The fiduciary (or his or her attorney) will generally |
| ### c. Com | > complete this form. Refer to the following table for  |
| pletion in | > a line-by-line description of required information.   |
| structions |                                                         |
+------------+---------------------------------------------------------+

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **NAME OF FIDUCIARY**          Self-Explanatory.

  **NAME OF VETERAN**            Self-Explanatory.

  **NAME OF BENEFICIARY**        Self-Explanatory.

  **LISTED SECURITIES ARE IN THE Self-Explanatory.
  POSSESSION OF:**               

  **SECTION I -- U. S. SAVINGS** 
  BONDS -- Lines 1 through 10    
  (If more than 10, continue on  
  the back of VA Form 21-4709,   
  or on a separate sheet.)       

  **DEPOSITOR ACCOUNT TITLE**    Enter the title exactly as it appears on
                                 the savings bond.

  **SERIAL NUMBER**              Self-Explanatory.

  **PURCHASE DATE**              Enter the date purchased for each bond.

  **PURCHASE PRICE**             Enter the purchase price for each bond.

  **TOTAL**                      Enter the total purchase price for all
                                 U.S. Savings Bonds listed.

  **Certification statement: "I  The certifying official enters the total
  CERTIFY THAT the U.S. Savings  number of itemized U. S. Savings Bonds
  bonds listed on lines 1        listed on the certificate in the
  thorough \_\_ were exhibited   designated blank. (The certifying
  to me ..."**                   official will generally be a bank
                                 official or the clerk of the court.)

  **DATE OF SIGNATURE**          The certifying official enters the date
                                 of his or her signature.
  ------------------------------ ----------------------------------------

Continued on next page

17\. VA Form 21-4709: Certificate as to Assets, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  ------------------------------ ----------------------------------------
  Block# and Title               Required Information

  **ADDRESS OF CERTIFYING        The certifying official enters his or
  OFFICIAL**                     her address.

  **SIGNATURE OF CERTIFYING      The certifying official certifies that
  OFFICIAL**                     the fiduciary exhibited the bonds to him
                                 or her by signing the certification. The
                                 certifying official will generally be a
                                 bank official or the clerk of the court.

  **SECTION II -- OTHER ASSETS   
  --** Lines 1 through 5 (If     
  more than 5, continue on the   
  back of VA Form 21-4709, or on 
  a separate sheet.)             

  **DEPOSITOR ACCOUNT**          Enter the title exactly as it appears on
                                 the account.

  **TYPE OF ASSET**              Self-Explanatory.

  **PURCHASE DATE**              Enter the date purchased for each asset.

  **PURCHASE PRICE**             Enter the purchase price for each asset.

  **INTEREST RATE**              Enter the interest rate payable on each
                                 asset, if applicable.

  **FACE VALUE OR NUMBER OF      Self-Explanatory.
  SHARES**                       

  **TOTAL**                      Enter the total face value or number of
                                 shares for all assets listed.

  **Certification statement: "I  The certifying official enters the total
  CERTIFY THAT the assets listed number of itemized assets listed on the
  on lines 1 thorough \_\_\_     certificate in the designated blank.
  were exhibited to me ..."**    (The certifying official will generally
                                 be a bank official or the clerk of the
                                 court.)

  **DATE OF SIGNATURE**          The certifying official enters the date
                                 of his or her signature.

  **ADDRESS OF CERTIFYING        The certifying official enters his or
  OFFICIAL**                     her address.

  **SIGNATURE AND TITLE OF       The certifying official certifies that
  CERTIFYING OFFICIAL**          the fiduciary exhibited the assets to
                                 him or her by signing the certification.
  ------------------------------ ----------------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

Continued on next page

17\. VA Form 21-4709: Certificate as to Assets, Continued

+------------+---------------------------------------------------------+
| ##### d.   | > File VA Form 21-4709 with the corresponding fiduciary |
| Filing and | > accounting. Refer to the following table for          |
|  Retention | > retention instructions:                               |
+------------+---------------------------------------------------------+

  ----------------------------- -----------------------------------------
  If the fiduciary is ...       Then ...

  a court-appointed fiduciary   dispose of older documents in accordance
  ...                           with RCS VB-1, Part I, as older
                                accountings are purged from the PGF.

  a federal fiduciary           retain for the life of the PGF.
  ----------------------------- -----------------------------------------

#### 18. VA Form 21-4716a: Adult Beneficiary Field Examination Request and Report 

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-4716a to:                              |
| a. What is |                                                         |
|  this form | -   request a field examination for appointment of a    |
|  used for? |     fiduciary for an incompetent adult, and             |
|            |                                                         |
|            | -   complete a field examination report for an          |
|            |     incompetent adult.                                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | Prepare VA Form 21-4716a to request field examinations  |
| ## b. When | for all adult beneficiaries under the supervision of    |
|  should th | the F&FE Activity within the VA.                        |
| is form be |                                                         |
|  prepared? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Manually prepare the form for use in the initial appointment field  |
| > examination request and report. It will be computer generated for   |
| > subsequent fiduciary beneficiary field examinations.                |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The field examiner's narrative report of field examination is also  |
| > completed on this form. Alternatively, the narrative report may be  |
| > completed on a separate page and referenced as an attachment on VA  |
| > Form 21-4716a.                                                      |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c.   | > Office personnel, field examiners or FBS will enter   |
| General In | > information on VA Form 21-4716a prior to assignment   |
| structions | > of the field examination request.                     |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The FE will                                                         |
|                                                                       |
| -   review and verify all information supplied with the request and   |
|     enter on the face of the form any changes or additions developed  |
|     during the field examination,                                     |
|                                                                       |
| -   explain any changes in the narrative portion of the report, and   |
|                                                                       |
| -   complete all items on the front of the form that are not          |
|     completed by office personnel or FBS.                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Information must be specific. Phrases such as "See Accounting,"     |
| > "See Report," "As needed," and "See PGF" are not acceptable.        |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Brief reports for the sole use of the reporting       |
|  d. Longha | > Veterans Service Center may be written in longhand,   |
| nd Reports | > if they are legible.                                  |
+------------+---------------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| #####      | > If the report includes information to be referred to  |
| e. Copies  | > another Veteran Service Center element and/or another |
| of Reports | > activity (i.e., VAMC, Insurance Center, etc.),        |
|            | > annotate Item 19 with instructions for referral.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f. A | > Refer to the following table to determine minimum     |
| ttachments | > attachments for adult field examination               |
|  -- Field  | > ***requests***:                                       |
| Examinatio |                                                         |
| n Requests |                                                         |
+------------+---------------------------------------------------------+

+-----------------------+----------------------------------------------+
| If the field          | You must include the following ...           |
| examination request   |                                              |
| is ...                |                                              |
+-----------------------+----------------------------------------------+
| an initial            | -   VA Form 21-592, Request for Appointment  |
| appointment field     |     of a Fiduciary, Custodian or Guardian,   |
| examination request   |                                              |
|                       | -   current electronic payment record, if    |
|                       |     applicable,                              |
|                       |                                              |
|                       | -   any documents provided with VA Form      |
|                       |     21-592 (i.e. Letters of Guardianship,    |
|                       |     letters from potential fiduciaries,      |
|                       |     etc.), and                               |
|                       |                                              |
|                       | -   any other pertinent information (i.e.,   |
|                       |     record of any VA insurance, etc.).       |
+-----------------------+----------------------------------------------+
| a successor initial   | -   current electronic payment record, if    |
| appointment field     |     applicable,                              |
| examination request   |                                              |
|                       | -   a copy of the last 21-4716a, and         |
|                       |                                              |
|                       | -   any documents relating to the need for a |
|                       |     change in payee (i.e. Successor Letters  |
|                       |     of Guardianship, letters of resignation  |
|                       |     from current fiduciaries, requests for   |
|                       |     appointment as successor fiduciary,      |
|                       |     etc.).                                   |
+-----------------------+----------------------------------------------+
| a                     | -   copy of the last field examination       |
| fiduciary-beneficiary |     report,                                  |
| field examination     |                                              |
| request               | -   current electronic payment record, if    |
|                       |     applicable, and                          |
|                       |                                              |
|                       | -   any other pertinent documents or         |
|                       |     correspondence indicating the need for   |
|                       |     advice or assistance.                    |
+-----------------------+----------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  f\. Attachments -- Field Examination Requests (continued)

  -----------------------------------------------------------------------

+-----------------------+----------------------------------------------+
| If the field          | You must include the following ...           |
| examination request   |                                              |
| is ...                |                                              |
+-----------------------+----------------------------------------------+
| an unscheduled        | -   a specific statement of the reason for   |
| fiduciary-beneficiary |     the unscheduled field examination        |
| field examination     |     request,                                 |
| request               |                                              |
|                       | -   a copy of the last field examination     |
|                       |     report,                                  |
|                       |                                              |
|                       | -   current electronic payment record, if    |
|                       |     applicable, and                          |
|                       |                                              |
|                       | -   any other pertinent documents or         |
|                       |     correspondence to support the request.   |
+-----------------------+----------------------------------------------+

+-----------------------------------------------------------------------+
| > Special issues identified by office personnel that need to be       |
| > addressed in the field examination report may be referenced in Item |
| > 22 and                                                              |
|                                                                       |
| -   briefly summarized in Item 24, or                                 |
|                                                                       |
| -   documented on VA Form 119, Report of Contact, and attached to the |
|     VA Form 21-4716a.                                                 |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > If block 24 is used to record the field examination   |
| ### g. Att | > report, or if the report is attached separately, the  |
| achments - | > beginning of the report should include a listing of   |
| - Field Ex | > any attachments such as VA Form 119 (Report of        |
| am Reports | > Contact), pleadings, court orders, letters of court   |
|            | > appointment, inventory of assets, surety bonds, sworn |
|            | > statements, birth certificates, death certificates,   |
|            | > and other documents requested by the requesting       |
|            | > element, that were obtained during the field          |
|            | > examination.                                          |
+------------+---------------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| ##         | > Items 1 through 10 are generally completed by FBS     |
| ### h. Com | > auto-fill or by office personnel on follow-up field   |
| pletion In | > examinations or on other than initial appointment     |
| structions | > field examinations. The following table provides      |
|            | > instructions for each field:                          |
+------------+---------------------------------------------------------+

+-------------+-----------------------------+-------------+-----------+
| Field \#    | Required Data               | IA and      | Scheduled |
| and Name    |                             | Unscheduled | FB Exam   |
|             |                             | FB          |           |
+-------------+-----------------------------+-------------+-----------+
| **TO**      | Enter the address of the    | Office      | FBS       |
|             | Fiduciary and Field         | Personnel   | auto-fill |
|             | Examination Activity that   |             |           |
|             | will complete the field     |             |           |
|             | examination                 |             |           |
+-------------+-----------------------------+-------------+-----------+
| **1. DATE   | Enter date the request is   | Office      | FBS       |
| OF          | received in the F&FE        | Personnel   | auto-fill |
| REQUEST**   | activity. Examples include  |             |           |
|             | but are no limited to the   | **DO NOT    | **DO NOT  |
|             | following:                  | CHANGE**    | CHANGE    |
|             |                             |             | unless FB |
|             | -   date VA Form 21-592 *is |             | field     |
|             |     received* by F&FE (per  |             | exam is   |
|             |     date stamp)             |             | changed   |
|             |                             |             | to a      |
|             | -   date of telephone call  |             | successor |
|             |     requesting appointment  |             | IA field  |
|             |     of a successor          |             | exam**    |
|             |     fiduciary               |             |           |
|             |                             |             |           |
|             | -   date allegation of      |             |           |
|             |     misuse is *received*    |             |           |
|             |     (per date stamp),       |             |           |
|             |                             |             |           |
|             | -   date potential misuse   |             |           |
|             |     is discovered by VA,    |             |           |
|             |                             |             |           |
|             | -   date accounting is      |             |           |
|             |     *received* by F&FE (per |             |           |
|             |     date stamp)             |             |           |
|             |                             |             |           |
|             | -   date of notice of death |             |           |
|             |     of a fiduciary is       |             |           |
|             |     *received* by F&FE (per |             |           |
|             |     date stamp)             |             |           |
+-------------+-----------------------------+-------------+-----------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+-----------------------------+-------------+-----------+
| Field \#    | Required Data               | IA and      | Scheduled |
| and Name    |                             | Unscheduled | FB Exam   |
|             |                             | FB          |           |
+-------------+-----------------------------+-------------+-----------+
| **2. TYPE   | Enter a checkmark in the    | Office      | FBS       |
| OF FIELD    | "INITIAL" block for initial | Personnel   | auto-fill |
| EXA         | appointment field exam      |             |           |
| MIN-ATION** | request (to include request |             |           |
|             | for a successor             |             |           |
|             | appointment).               |             |           |
|             |                             |             |           |
|             | FBS automatically enters    |             |           |
|             | "P" for personal contact    |             |           |
|             | and "A" for alternate       |             |           |
|             | contact in the "FID BEN"    |             |           |
|             | block for scheduled         |             |           |
|             | fiduciary-beneficiary exam  |             |           |
|             | requests.                   |             |           |
+-------------+-----------------------------+-------------+-----------+
| **3. SOCIAL | Enter the veteran's Social  | Office      | FBS       |
| SECURITY    | Security number.            | Personnel   | auto-fill |
| NUMBER**    |                             |             |           |
+-------------+-----------------------------+-------------+-----------+
| **4. VA     | Self-explanatory            | Office      | FBS       |
| FILE        |                             | Personnel   | auto-fill |
| NUMBER**    |                             |             |           |
+-------------+-----------------------------+-------------+-----------+
| **5.        | Enter the territorial code  | Office      | FBS       |
| T           | for the area where the      | Personnel   | auto-fill |
| ERRI-TORIAL | *beneficiary* resides. If   |             |           |
| CODE**      | your station is responsible |             |           |
|             | for beneficiaries residing  |             |           |
|             | in foreign countries,       |             |           |
|             | establish codes for those   |             |           |
|             | countries under your        |             |           |
|             | jurisdiction.               |             |           |
|             |                             |             |           |
|             | Use code 001 for other      |             |           |
|             | cases where the beneficiary |             |           |
|             | does not reside in your     |             |           |
|             | jurisdiction, e.g.,         |             |           |
|             | beneficiaries who live in   |             |           |
|             | another state but whose     |             |           |
|             | fiduciary resides in your   |             |           |
|             | jurisdiction.               |             |           |
+-------------+-----------------------------+-------------+-----------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+-----------------------------+-------------+-----------+
| Field \#    | Required Data               | IA and      | Scheduled |
| and Name    |                             | Unscheduled | FB Exam   |
|             |                             | FB          |           |
+-------------+-----------------------------+-------------+-----------+
| **6. TYPE   | Enter check in appropriate  | FE          | FBS       |
| OF PAYEE**  | block to designate the type |             | auto-fill |
|             | of fiduciary appointment.   |             |           |
|             | Options include:            |             |           |
|             |                             |             |           |
|             | A.  CORP. COURT FIDUCIARY   |             |           |
|             |                             |             |           |
|             | B.  IND. COURT FIDUCIARY    |             |           |
|             |                             |             |           |
|             | C.  LEGAL CUST.             |             |           |
|             |                             |             |           |
|             | D.  SUP. DIRECT PAYMENT     |             |           |
|             |                             |             |           |
|             | E.  SUPT. BUR. IND. AFFAIRS |             |           |
|             |                             |             |           |
|             | F.  CUSTODIAN-IN-FACT       |             |           |
|             |                             |             |           |
|             | G.  SPOUSE-PAYEE            |             |           |
|             |                             |             |           |
|             | H.  INST. AWARD             |             |           |
+-------------+-----------------------------+-------------+-----------+
| **7. NAME   | Self-explanatory            | Office      | FBS       |
| OF          |                             | Personnel   | auto-fill |
| VETERAN**   |                             |             |           |
+-------------+-----------------------------+-------------+-----------+
| **8. TYPE   | Enter check in appropriate  | Office      | FBS       |
| OF          | block to designate the type | Personnel   | auto-fill |
| BEN         | of beneficiary. Options     |             |           |
| E-FICIARY** | include:                    |             |           |
|             |                             |             |           |
|             | A.  VETERAN                 |             |           |
|             |                             |             |           |
|             | B.  WIDOW/WIDOWER           |             |           |
|             |                             |             |           |
|             | C.  HELPLESS CHILD          |             |           |
|             |                             |             |           |
|             | D.  DEP. MOTHER             |             |           |
|             |                             |             |           |
|             | E.  DEP. FATHER             |             |           |
|             |                             |             |           |
|             | F.  OTHER                   |             |           |
|             |                             |             |           |
|             | Explain entries in Item 8F  |             |           |
|             | in Item 2, Comments.        |             |           |
+-------------+-----------------------------+-------------+-----------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ----------------------- ------------------------------ -------------- ------------
  Field \# and Name       Required Data                  IA and         Scheduled FB
                                                         Unscheduled FB Exam

  **9A. IS BENE-FICIARY   Check the appropriate block    Office         Office
  INSTITU-TIONALIZED?**   (i.e., \[1\] YES, or \[2\] NO) Personnel or   Personnel or
                          to indicate if the beneficiary FE             FE
                          is institutionalized.                         
                          Institutionalized is defined                  
                          as being in any facility in                   
                          which the beneficiary is                      
                          receiving professional care,                  
                          such as a nursing home or                     
                          hospital, including VA                        
                          domiciliary care and                          
                          incarceration in penal                        
                          facilities or mental                          
                          institutions. This includes                   
                          private pay as well as VA                     
                          contract.                                     

  **9B. DATE ENTERED**    Enter the date of admission    Office         Office
                          for institutionalized          Personnel      Personnel or
                          beneficiaries, if response to                 FE
                          9A is "YES."                                  

  **10A. NAME, ADDRESS    Enter the name and address of  FE             FBS
  AND TELE-PHONE NUMBER   the fiduciary as it appears in                auto-fill
  OF PAYEE**              payment records.                              

  **10B. SOCIAL SECURITY  Self-explanatory.              FE             FBS
  NUMBER OF PAYEE**                                                     auto-fill
  ----------------------- ------------------------------ -------------- ------------

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------+-----------------------------+-------------+-----------+
| Field \#    | Required Data               | IA and      | Scheduled |
| and Name    |                             | Unscheduled | FB Exam   |
|             |                             | FB          |           |
+-------------+-----------------------------+-------------+-----------+
| **10C.      | Enter the beneficiary's     | FE          | FBS       |
| NAME,       | name, if other than the     |             | auto-fill |
| ADDRESS AND | veteran.                    |             |           |
| TELEPHONE   |                             |             |           |
| NUMBER OF   | Enter the beneficiary's     |             |           |
| BEN         | address and telephone       |             |           |
| E-FICIARY** | number, if different from   |             |           |
|             | the payee.                  |             |           |
+-------------+-----------------------------+-------------+-----------+

+-----------------------------------------------------------------------+
| > Each element under Fields 11 through 15 contains 2 columns for      |
| > information. The first column is labeled **"FROM P.G.F."** and the  |
| > second is labeled **"FROM FLD. EXAMINER."**                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Office personnel complete the **"FROM P.G.F."** column using data   |
| > from                                                                |
|                                                                       |
| -   VA Form 21-592 and supporting material for initial appointment    |
|     cases and                                                         |
|                                                                       |
| -   from the PGF and most recent accounting (if applicable) for       |
|     fiduciary-beneficiary field examination requests.                 |
+-----------------------------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| h\.        | > The field examiner will use the **"FROM FLD.          |
| Completion | > EXAMINER"** column to                                 |
| In         |                                                         |
| structions | -   verify and/or correct information provided by       |
| (          |     office personnel, and                               |
| continued) |                                                         |
|            | -   provide information not previously available.       |
+------------+---------------------------------------------------------+

+----------------+-----------------------------------------------------+
| Field \# and   | Required Data                                       |
| Name           |                                                     |
+----------------+-----------------------------------------------------+
| **11. VALUE OF | AMOUNT IN HANDS OF PAYEE AS OF (DATE): Enter the    |
| ESTATE**       | amount and the date that information was accurate.  |
|                |                                                     |
|                | -   If the request is an IA, this information will  |
|                |     likely not be available to office personnel.    |
|                |     Leave the **"FROM P.G.F."**. column blank if    |
|                |     the information is not available.               |
|                |                                                     |
|                | -   If the request is a FB, this information will   |
|                |     generally come from the last field examination  |
|                |     or accounting. Include all readily liquid funds |
|                |     such as checking accounts, savings accounts,    |
|                |     and certificates of deposit.                    |
+----------------+-----------------------------------------------------+
|                | AMOUNT IN PFOP AT D.P.C. VAMC -- Circle if          |
|                | appropriate to specify if funds are at the D.P.C.,  |
|                | or a VAMC activity. Enter the amount.               |
|                |                                                     |
|                | -   If the request is an IA, this information will  |
|                |     come from VA From 21-592 and/or payment         |
|                |     records.                                        |
|                |                                                     |
|                | -   If the request is a FB, this information will   |
|                |     generally come from the last field examination  |
|                |     and/or payment records.                         |
+----------------+-----------------------------------------------------+
|                | VALUE OF REAL ESTATE -- Enter the estimated or, if  |
|                | known, the assessed or appraised value of real      |
|                | estate (including his or her home) belonging to the |
|                | beneficiary.                                        |
|                |                                                     |
|                | -   If the request is an IA, this information will  |
|                |     likely not be available to office personnel.    |
|                |     Leave the **"FROM P.G.F."**. column blank if    |
|                |     the information is not available.               |
|                |                                                     |
|                | -   If the request is a FB, the information will    |
|                |     generally come form the last field examination  |
|                |     report and/or VA Form 21-4707.                  |
|                |                                                     |
|                | -   Field examiners must enter this information in  |
|                |     the **"FROM FLD. EXAMINER"** column, and        |
|                |     identify in the narrative report how value was  |
|                |     obtained.                                       |
+----------------+-----------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-----------------+----------------------------------------------------+
| Field \# and    | Required Data                                      |
| Name            |                                                    |
+-----------------+----------------------------------------------------+
|                 | IRREVOCABLE BURIAL TRUST -- Self-Explanatory.      |
|                 | Enter if applicable.                               |
|                 |                                                    |
|                 | -   If the request is an IA, this information will |
|                 |     likely not be available to office personnel.   |
|                 |     Leave the **"FROM P.G.F."** column blank if    |
|                 |     the information is not available.              |
|                 |                                                    |
|                 | -   If the request is a FB, this information will  |
|                 |     generally come from the last field examination |
|                 |     report or the fiduciary's most recent          |
|                 |     accounting.                                    |
+-----------------+----------------------------------------------------+
| **12. TOTAL OF  | COMP/D.I.C./PEN/A&A/HB -- Check the appropriate    |
| VA AWARD(S)**   | block to indicate the type of benefit(s) payable.  |
|                 | Enter the current benefit amount shown in          |
|                 | electronic payment records.                        |
|                 |                                                    |
|                 | If benefit payable is pension, enter the type,     |
|                 | e.g., Old Law, Sec. 306, or PL-588.                |
+-----------------+----------------------------------------------------+
|                 | OTHER -- Specify the type and amount of any other  |
|                 | VA benefit. Enter the current benefit amount shown |
|                 | in electronic payment records.                     |
|                 |                                                    |
|                 | -   If the request is an IA, this information will |
|                 |     likely not be available to office personnel.   |
|                 |     Leave the **"FROM P.G.F."** column blank if    |
|                 |     the information is not available.              |
|                 |                                                    |
|                 | -   If the request is a FB, information for the    |
|                 |     **"FROM P.G.F."** column will generally come   |
|                 |     from the last field examination report or the  |
|                 |     fiduciary's most recent accounting.            |
+-----------------+----------------------------------------------------+
| **13. VA        | PAYEE/DIRECT DEPOSIT -- Enter the net amount of VA |
| DISTRI-BUTION   | benefit paid to the payee for the beneficiary, as  |
| OF MONTHLY      | shown in electronic payment records.               |
| PAYMENTS**      |                                                    |
|                 | Check DIRECT DEPOSIT if applicable.                |
+-----------------+----------------------------------------------------+
|                 | DEPENDENTS -- Enter the net amount of VA benefit   |
|                 | apportioned to dependent(s), as shown on current   |
|                 | electronic payment record.                         |
+-----------------+----------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------------+--------------------------------------------------+
| Field \# and Name | Required Data                                    |
+-------------------+--------------------------------------------------+
|                   | PFOP -- If applicable, enter the amount withheld |
|                   | and deposited into a PFOP account, as shown in   |
|                   | electronic payment records.                      |
+-------------------+--------------------------------------------------+
|                   | INSTITUTION FOR CARE AND MAINTENANCE -- Leave    |
|                   | blank. This block became obsolete with repeal of |
|                   | the Estate Limitation Law.                       |
+-------------------+--------------------------------------------------+
| **14. OTHER       | SOCIAL SECURITY/GROSS/NET AFTER MEDICARE OR      |
| INCOME**          | WAIVER DEDUCTION                                 |
|                   |                                                  |
|                   | Enter the amount of Social Security, as shown in |
|                   | SHARE.                                           |
+-------------------+--------------------------------------------------+
|                   | OTHER -- Enter the source and amount of any      |
|                   | other income the beneficiary receives.           |
|                   |                                                  |
|                   | -   If the request is an IA, this information    |
|                   |     will likely not be available to office       |
|                   |     personnel. Leave the **"FROM P.G.F."**       |
|                   |     column blank if the information is not       |
|                   |     available.                                   |
|                   |                                                  |
|                   | -   If the request is a FB, information for the  |
|                   |     **"FROM P.G.F."** column will generally come |
|                   |     from the last field examination report or    |
|                   |     the fiduciary's most recent accounting.      |
+-------------------+--------------------------------------------------+
| **15. MONTHLY     | BENEFICIARY SUPPORT -- Enter the amount          |
| EXPEND-ITURES**   | authorized for the beneficiary's room & board    |
|                   | expenses (food and rent or mortgage).            |
|                   |                                                  |
|                   | -   If the request is an IA, this information    |
|                   |     will likely not be available to office       |
|                   |     personnel. Leave the **"FROM P.G.F."**       |
|                   |     column blank if the information is not       |
|                   |     available.                                   |
|                   |                                                  |
|                   | -   If the request is a FB, information for the  |
|                   |     **"FROM P.G.F."** column will generally come |
|                   |     from the last field examination report or    |
|                   |     the fiduciary's most recent accounting.      |
+-------------------+--------------------------------------------------+
|                   | BENEFICIARY INCIDENTALS -- Enter the amount      |
|                   | authorized for the beneficiary's incidental      |
|                   | needs (e.g., magazines, cigarettes, haircuts,    |
|                   | movies, etc.).                                   |
+-------------------+--------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ------------------- ---------------------------------------------------
  Field \# and Name   Required Data

                      BENEFICIARY OTHER -- Enter the amount and purpose
                      of any other special allowance authorized for the
                      beneficiary. This amount includes regular payments
                      for items such as clothing, doctor visits,
                      companion care, etc. Identify the reasons for the
                      payments.

                      DEPENDENT SUPPORT -- Enter the amount authorized by
                      VA and furnished by the fiduciary for support of
                      any dependent.
  ------------------- ---------------------------------------------------

+-----------------------------------------------------------------------+
| > The field examiner completes Items 16 through 23 when submitting    |
| > his or her final report.                                            |
+-----------------------------------------------------------------------+

+-------------------+--------------------------------------------------+
| Field \# and Name | Required Data                                    |
+-------------------+--------------------------------------------------+
| **16. DEPENDENTS  | Check the appropriate block to reflect any       |
| OF BENEFICIARY**  | dependents recognized by VA. Options include:    |
|                   |                                                  |
|                   | A.  SPOUSE                                       |
|                   |                                                  |
|                   | B.  MOTHER                                       |
|                   |                                                  |
|                   | C.  FATHER                                       |
|                   |                                                  |
|                   | D. CHILD(REN) (specify number)                   |
+-------------------+--------------------------------------------------+
|                   | Check appropriate block to reflect all           |
|                   | individuals LIVING IN BENEFICIARY'S HOUSEHOLD.   |
|                   | Options include:                                 |
|                   |                                                  |
|                   | A.  SPOUSE                                       |
|                   |                                                  |
|                   | B.  MOTHER                                       |
|                   |                                                  |
|                   | C.  FATHER                                       |
|                   |                                                  |
|                   | D. CHILD(REN)                                    |
+-------------------+--------------------------------------------------+
| **17. PAYEE       | Select "YES" or "NO," as appropriate. If yes is  |
| DESIGNATION**     | selected, also select all other blocks that      |
|                   | apply. Options include:                          |
|                   |                                                  |
|                   | A.  INITIAL                                      |
|                   |                                                  |
|                   | B.  SUCCESSOR                                    |
|                   |                                                  |
|                   | C.  SPOUSE-PAYEE CONFIRMED                       |
|                   |                                                  |
|                   | D.  CERTIFY PAYEE                                |
|                   |                                                  |
|                   | E.  VA FORM 27-555a ATTACHED                     |
+-------------------+--------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------------+--------------------------------------------------+
| Field \# and Name | Required Data                                    |
+-------------------+--------------------------------------------------+
| **18. FIDUCIARY   | Use this field for ***all*** federal fiduciary   |
| FEE AUTHORIZED**  | cases. Do ***not*** use this field for           |
|                   | court-appointed fiduciary cases.                 |
|                   |                                                  |
|                   | Select "YES" or "NO," as appropriate.            |
|                   |                                                  |
|                   | If "YES" is selected, state                      |
|                   |                                                  |
|                   | -   the negotiated percentage (not to exceed 4%, |
|                   |     and/or                                       |
|                   |                                                  |
|                   | -   the flat monthly fee recommended (again, not |
|                   |     to exceed 4% of VA income).                  |
|                   |                                                  |
|                   |     The "flat" fee will generally be used in     |
|                   |     cases that involve large retroactive         |
|                   |     benefits when the FE negotiates a flat fee   |
|                   |     for receiving the benefit and establishing   |
|                   |     appropriate accounts. For example, the FE    |
|                   |     might recommend a 3% commission on monthly   |
|                   |     benefits and a flat \$300 commission for     |
|                   |     receiving and depositing the retroactive     |
|                   |     funds. The 4716a would then be completed to  |
|                   |     reflect "3% and \$300 on retro."             |
|                   |                                                  |
|                   | Narrative report must document the need for a    |
|                   | fiduciary fee recommendation.                    |
+-------------------+--------------------------------------------------+
| **19. VA FORMS    | Self-Explanatory. Always indicate whether the    |
| COMPLETED OR LEFT | forms were left with the fiduciary or are        |
| WITH FIDUCIARY**  | attached to the report.                          |
+-------------------+--------------------------------------------------+
| **20A. DATE OF    | Self-Explanatory. In addition to the date of the |
| NEXT FIELD        | next field examination, specify the type of      |
| EXAMINATION**     | field examination recommended (e.g., personal or |
|                   | alternate).                                      |
+-------------------+--------------------------------------------------+
| **20B. ACCOUNT    | Self-Explanatory. In court-appointed fiduciary   |
| DUE DATE**        | cases, this date will be established by court.   |
|                   | The FE will establish the account date for       |
|                   | federal fiduciary cases.                         |
+-------------------+--------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

+-------------------+--------------------------------------------------+
| Field \# and Name | Required Data                                    |
+-------------------+--------------------------------------------------+
| **21. FINANCIAL   |                                                  |
| ACCOUNT NUMBERS** |                                                  |
+-------------------+--------------------------------------------------+
| **21A. SAVINGS**  | Enter the account number(s) for any savings      |
|                   | account(s) managed by the fiduciary for the      |
|                   | beneficiary, from data in previous field         |
|                   | examination report.                              |
+-------------------+--------------------------------------------------+
| **21B. CHECKING** | Enter the account number(s) for any checking     |
|                   | account(s) managed by the fiduciary for the      |
|                   | beneficiary, from data in previous field         |
|                   | examination report.                              |
+-------------------+--------------------------------------------------+
| **21C. OTHER**    | Enter the account number(s) and type of account  |
|                   | for any other account(s) managed by the          |
|                   | fiduciary for the beneficiary, from data in      |
|                   | previous field examination report..              |
+-------------------+--------------------------------------------------+
| **22. OTHER       | Enter special instructions for office personnel  |
| ACTION REQUIRED** | in processing or controlling the case.           |
+-------------------+--------------------------------------------------+
| **23. STATISTICAL |                                                  |
| TREND ANALYSIS    |                                                  |
| DATA:** Complete  |                                                  |
| each applicable   |                                                  |
| block.            |                                                  |
| Incorporate       |                                                  |
| supporting        |                                                  |
| evidence into the |                                                  |
| Item 24           |                                                  |
| narrative. When   |                                                  |
| referral to the   |                                                  |
| Office of the     |                                                  |
| Inspector General |                                                  |
| (OIG) or Regional |                                                  |
| Counsel (RC) is   |                                                  |
| necessary,        |                                                  |
| annotate Item 22  |                                                  |
| to ensure that    |                                                  |
| these cases are   |                                                  |
| first referred to |                                                  |
| a Legal           |                                                  |
| Instruments       |                                                  |
| Examiner.         |                                                  |
+-------------------+--------------------------------------------------+
| **23A. ADVERSE    | Check this block if any unhealthy or             |
| CONDI-TIONS**     | unacceptable living conditions are identified    |
|                   | which affect the beneficiary.                    |
+-------------------+--------------------------------------------------+
| **23B. MISUSE OF  | Enter a checkmark when misuse of OTHER GOV'T or  |
| FUNDS**           | OTHER/UNIDENTIFIED funds is identified.          |
|                   |                                                  |
|                   | **DO NOT USE THE "VA" FIELD AS MISUSE OF VA      |
|                   | FUNDS MAY BE REPORTED ONLY AFTER AN OFFICIAL     |
|                   | DETERMINATION**                                  |
|                   |                                                  |
|                   | Enter the estimated value of OTHER GOV'T or      |
|                   | OTHER/UNIDENTIFIED funds misused.                |
+-------------------+--------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

  -----------------------------------------------------------------------
  h\. Completion Instructions (continued)

  -----------------------------------------------------------------------

  ------------------- ---------------------------------------------------
  Field \# and Name   Required Data

  **23C. POSSIBLE     Check this block if any possible overpayment in VA
  OVERPAYMENT REFER   benefits is identified. Identify where the case
  CASE TO:**          should be referred for action.

  **23D. CASE TO BE   Check this block if the case is to be referred to
  REFERRED TO RC      Regional Counsel (RC) for legal action. Enter the
  ESTIMATED DOLLAR    total estimated dollar amount involved.
  AMOUNT INVOLVED**   

  **23E. CASE TO BE   Check this block if the case is to be referred to
  REFERRED TO IG      the Office of the Inspector General (OIG) for any
  ESTIMATED DOLLAR    action. Enter the total estimated dollar amount
  AMOUNT INVOLVED**   involved.

  **23F. POSSIBLE     Check this block if any possible underpayment in VA
  UNDERPAY-MENT REFER benefits is identified. Identify where the case
  CASE TO:**          should be referred for action.
  ------------------- ---------------------------------------------------

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| h\.        | > The field examiner generally completes Item 24,       |
| Completion | > however, office personnel may also make entries in    |
| In         | > this field.                                           |
| structions |                                                         |
| (          |                                                         |
| continued) |                                                         |
+------------+---------------------------------------------------------+

+-------------------+--------------------------------------------------+
| Field \# and Name | Required Data                                    |
+-------------------+--------------------------------------------------+
| **24. COMMENTS**  | Office personnel may make comments related to    |
|                   | specific issues to be addressed by the FE and    |
|                   | reference these comments in Item 22 of this      |
|                   | form.                                            |
|                   |                                                  |
|                   | The FE will provide a narrative report covering  |
|                   | all required information as outlined in the      |
|                   | Fiduciary Program Manual.                        |
+-------------------+--------------------------------------------------+

+-----------------------------------------------------------------------+
| > The field examiner that completes the field examination report      |
| > always completes Items 25 and 26.                                   |
+-----------------------------------------------------------------------+

  ------------------- ---------------------------------------------------
  Field \# and Name   Required Data

  **25. SIGNATURE OF  Signature of individual completing the field
  AUTHORIZED OFFICIAL examination. This will generally be the Field
  AND OFFICE**        Examiner.

  **26. DATE OF       Date report is completed and signed.
  REPORT**            
  ------------------- ---------------------------------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

Continued on next page

18\. VA Form 21-4716a: Adult Beneficiary Field Examination Request and
Report, Continued

+------------+---------------------------------------------------------+
| ##### i.   | > Refer to the following table for filing instructions: |
| Filing and |                                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

  ----------------------- -----------------------------------------------
  If the fiduciary is ... File VA Form 21-4716a on...

  a federal fiduciary,    the right flap.

  court-appointed,        an appropriately designated flap, using the
                          same location (i.e., left, center, or right) in
                          all cases.
  ----------------------- -----------------------------------------------

+-----------------------------------------------------------------------+
| > Retain VA Form 21-4716a for the life of the file.                   |
+-----------------------------------------------------------------------+

#### 19. VA Form 21-4718, Account Book 

+------------+---------------------------------------------------------+
| #          | > VA Form 21-4718 is a 3 ½ x 8 ½ booklet for recording  |
| #### a. In |                                                         |
| troduction | -   money received,                                     |
|            |                                                         |
|            | -   money spent,                                        |
|            |                                                         |
|            | -   a summary of account activity, and                  |
|            |                                                         |
|            | -   a record of investments.                            |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** Formerly VA Form 27-4718. Some existing stock may carry |
| > this number.                                                        |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > You may wish to provide this form to individual       |
| ## b. When | > fiduciaries at the time of certification and          |
|  should yo | > thereafter upon request as a convenient way to record |
| u furnish  | > their fiduciary activity.                             |
| this form? |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Since professional fiduciaries and corporate fiduciaries generally  |
| > have established recordkeeping procedures, this form will generally |
| > be of little or no value to them.                                   |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The fiduciary completes this form in its entirety.    |
| ### c. Com | > The fiduciary will enter his or her name and address, |
| pletion In | > the beneficiary's name, the veteran's name, and file  |
| structions | > number on the face of the form.                       |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Page 1 contains a summary of fiduciary responsibilities. Page 2     |
| > contains information about the Privacy Act. Page 3 contains         |
| > instructions for use of the form.                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The fiduciary reports all income received for the beneficiary on    |
| > pages 4 and 5.                                                      |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The fiduciary reports all money spent for the beneficiary on pages  |
| > 6 through 11.                                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > The fiduciary enters his or her recapitulation, or summary, on      |
| > pages 12 and 13, and itemizes investments on pages 14 and 15.       |
+-----------------------------------------------------------------------+

Continued on next page

19\. VA Form 21-4718, Account Book, Continued

+------------+---------------------------------------------------------+
| ##### d.   | > The fiduciary should generally retain this form for   |
| Filing and | > his or her records. If the fiduciary includes the VA  |
|  Retention | > Form 21-4718 in support of his or her accounting,     |
|            | > return it upon approval of the accounting.            |
+------------+---------------------------------------------------------+

#### 20. VA Form 21-4718a: Certificate of Balance on Deposit and Authorization to Disclose Financial Records 

+------------+---------------------------------------------------------+
| ##### a.   | > VA Form 21-4718a is used to                           |
| What is th |                                                         |
| e purpose  | -   verify funds held in federally insured checking and |
| of VA Form |     savings accounts at the end of an accounting        |
|  21-4718a? |     period, and                                         |
|            |                                                         |
|            | -   authorize the financial institution to              |
|            |     independently verify information on the document at |
|            |     VA request.                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > This document may also be used to verify assets in non-accounting   |
| > cases when VA-derived assets exceed \$5000                          |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | Provide this form when a fiduciary recognized by VA     |
| ## b. When | reports funds on deposit in federally insured checking  |
|  should yo | and/or savings accounts at the end of an accounting     |
| u provide  | period.                                                 |
| this form? |                                                         |
+------------+---------------------------------------------------------+

  -----------------------------------------------------------------------
  In non-accounting cases, provide this form to the fiduciary to report
  VA-derived assets exceeding \$5000 at the time of the
  fiduciary-beneficiary field examination. This form is not required if
  funds can be verified by other methods (i.e., viewing the original bank
  statement).

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  The fiduciary must furnish the original, unaltered document to VA. If
  the document received contains alterations or other questionable
  information, return it to the financial institution with a request for
  clarification and entry of missing information.

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| Documents not fully completed, must be returned to the fiduciary with |
| a request that they have the financial institution re-certify,        |
| providing all required information:                                   |
|                                                                       |
| -   name and address of financial institution,                        |
|                                                                       |
| -   account type,                                                     |
|                                                                       |
| -   account number,                                                   |
|                                                                       |
| -   account registration (title),                                     |
|                                                                       |
| -   account balance and effective date,                               |
|                                                                       |
| -   interest rate and total interest earned during the period covered |
|     by the accounting,                                                |
|                                                                       |
| -   signature and title of authorized official, and                   |
|                                                                       |
| -   the official stamp or seal of the financial institution).         |
+-----------------------------------------------------------------------+

Continued on next page

20\. VA Form 21-4718a: Certificate of Balance on Deposit and
Authorization to Disclose Financial Records, Continued

+------------+---------------------------------------------------------+
| ##         | > Refer to the following table for line-by-line         |
| ### c. Com | > completion instructions:                              |
| pletion in |                                                         |
| structions |                                                         |
+------------+---------------------------------------------------------+

  -------------------------- --------------- ----------------------------
  Block# and Title ...       Completed By    Required Information ...
                             ...             

  **(SEAL OR STAMP OF        Financial       Self-Explanatory
  FINANCIAL INSTITUTION)**   Institution     

  **1. NAME OF FIDUCIARY**   Fiduciary       Self-Explanatory

  **2. NAME OF BENEFICIARY** Fiduciary       Self-Explanatory

  **3. VA FILE NUMBER**      Fiduciary       Self-Explanatory

  **The financial                            
  institution *only* must                    
  complete the following                     
  fields.**                                  

  **4A. NAME OF FINANCIAL    Financial       Self-Explanatory
  INSTITUTION**              Institution     

  **4B. ADDRESS OF FINANCIAL Financial       Self-Explanatory
  INSTITUTION**              Institution     

  **5. DATA IN ITEM 6 WAS    Financial       The financial institution
  ACCURATE AS OF**           Institution     enters the date of the
                                             certified balance entered in
                                             Item 6D. This should be the
                                             ending date of the
                                             accounting period.

  **6. ACCOUNT INFORMATION**                 

  **TYPE OF ACCOUNT (A)**    Financial       Self-Explanatory.
                             Institution     

  **ACCOUNT NUMBER (B)**     Financial       Self-Explanatory.
                             Institution     

  **DEPOSITOR ACCOUNT TITLE  Financial       The financial institution
  (C)**                      Institution     should enter the title
                                             exactly as it appears on the
                                             account.

  **BALANCE (D)**            Financial       Self-Explanatory.
                             Institution     
  -------------------------- --------------- ----------------------------

Continued on next page

20\. VA Form 21-4718a: Certificate of Balance on Deposit and
Authorization to Disclose Financial Records, Continued

  -----------------------------------------------------------------------
  c\. Completion instructions (continued)

  -----------------------------------------------------------------------

  -------------------------- --------------- ----------------------------
  Block# and Title ...       Completed By    Required Information ...
                             ...             

  **INTEREST EARNED/PAID     Financial       The financial institution
  SINCE -- AMOUNT (E)**      Institution     should enter the total
                                             amount of interest paid on
                                             the account during the
                                             accounting period (the date
                                             in Block 6(F) through Block
                                             5.)

  **INTEREST EARNED/PAID     Financial       The financial institution
  SINCE -- DATE (F)**        Institution     should enter the end date of
                                             the last accounting period.

  **CURRENT INTEREST RATE    Financial       Self-Explanatory.
  (G)**                      Institution     

  **7A. SIGNATURE OF         Financial       Self-Explanatory.
  CERTIFYING FINANCIAL       Institution     
  INSTITUTION OFFICIAL**                     

  **7B. TITLE OF CERTIFYING  Financial       Self-Explanatory.
  OFFICIAL**                 Institution     

  **7C. DATE SIGNED**        Financial       Self-Explanatory.
                             Institution     

  **The fiduciary *only*                     
  must complete the                          
  following fields.**                        

  **8. Conditions of         **N/A**         **N/A**
  Authorization**                            

  **9. Fiduciary's Statement **N/A**         **N/A**
  of Understanding**                         

  **10A. SIGNATURE OF        Fiduciary       Self-Explanatory. Note that
  FIDUCIARY**                                VA cannot ***require*** a
                                             fiduciary to sign this
                                             authorization.

  **10B. DATE SIGNED**       Fiduciary       Self-Explanatory.
  -------------------------- --------------- ----------------------------

+-----------------------------------------------------------------------+
| > ***Note:*** Shaded areas represent ***minimum*** required entries.  |
| > These fields require entry in ***all*** cases. Other fields must be |
| > completed as applicable.                                            |
+-----------------------------------------------------------------------+

Continued on next page

20\. VA Form 21-4718a: Certificate of Balance on Deposit and
Authorization to Disclose Financial Records, Continued

+------------+---------------------------------------------------------+
| ##### d.   | > Refer to the following table for filing and retention |
| Filing and | > requirements.                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

  --------------------- ------------------------------- -----------------
  If the fiduciary is   File VA Form 21-4718a ...       And retain it ...
  ...                                                   

  court-appointed       in the PGF, with the associated according to
                        accounting                      retention
                                                        requirements for
                                                        court
                                                        accountings. See
                                                        Topic 12 in this
                                                        Program Guide for
                                                        further
                                                        information.

  a federal fiduciary   in the PGF, with the associated for the life of
                        accounting (or field            the PGF.
                        examination in non-accounting   
                        cases)                          
  --------------------- ------------------------------- -----------------

#### 21. VA Form 21-8473: Withdrawal Agreement 

+------------+---------------------------------------------------------+
| #####      | > Use VA Form 21-8473 to                                |
| a. What is |                                                         |
|  this form | -   create a 3-party contract between VA, the           |
|  used for? |     fiduciary, and a financial institution, and         |
|            |                                                         |
|            | -   restrict withdrawal of funds from a fiduciary       |
|            |     account without VSCM approval.                      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | The field examiner will generally make the decision to  |
| ## b. When | require a withdrawal agreement at the time of the       |
|  should th | initial appointment field examination. In other         |
| is form be | instances, s/he may make this decision at the time of a |
|  prepared? | fiduciary-beneficiary field examination, or the LIE may |
|            | make it at the time of an accounting analysis.          |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Use this form when you determine that protection is needed and a    |
| > surety bond is either not available or cost-prohibitive.            |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  You will rarely use this form in Spouse Payee situations. When you
  determine that protection is advisable in these cases, you should
  consider some other form of fiduciary arrangement.

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| > Although most frequently used in federal fiduciary cases, you may   |
| > also use a withdrawal agreement for a court-appointed fiduciary     |
| > when the amount of surety bond is not adequate to protect all       |
| > VA-derived funds.                                                   |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Complete this document in triplicate. Retain the      |
| ### c. Com | > original in the PGF and give copies to both the       |
| pletion in | > fiduciary and the financial institution.              |
| structions |                                                         |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Enter the veteran's full name and VA file number for case           |
| > identification purposes.                                            |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Complete paragraph one by inserting the beneficiary's name in the   |
| > blank to identify the incompetent.                                  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Use the blank space between paragraphs one and two to state any     |
| > unique provisions. For instance, you may stipulate that, in         |
| > addition to the lump sum deposit; a portion of the beneficiary's VA |
| > benefit must also be conserved each month. An appropriate entry     |
| > might read:                                                         |
| >                                                                     |
| > "Whereas, the *\< name of financial institution \>* agrees to       |
| > release a maximum amount of \$ \_\_\_\_\_ per month to the Legal    |
| > Custodian; and"                                                     |
+-----------------------------------------------------------------------+

Continued on next page

21\. VA Form 21-8473: Withdrawal Agreement, Continued

+------------+---------------------------------------------------------+
| c\.        | > If you choose to include a monthly savings provision  |
| Completion | > in the withdrawal agreement, you must also            |
| in         |                                                         |
| structions | -   ensure that benefits are direct deposited to the    |
| (          |     subject account, and                                |
| continued) |                                                         |
|            | -   update the agreement whenever the specified         |
|            |     allowance changes.                                  |
+------------+---------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Complete paragraph two to include the                               |
|                                                                       |
| -   name and location of the financial institution,                   |
|                                                                       |
| -   the amount of VA funds to be deposited in the restricted account, |
|                                                                       |
| -   name of the beneficiary,                                          |
|                                                                       |
| -   name of the fiduciary, and                                        |
|                                                                       |
| -   financial institution's account number.                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Execute the agreement by                                            |
|                                                                       |
| -   entering the date of signing, and obtaining signatures of         |
|                                                                       |
| -   the Veterans Service Center Manager (VSCM) or designee,           |
|                                                                       |
| -   legal custodian,                                                  |
|                                                                       |
| -   financial institution.                                            |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > Finally, enter the name and title of the individual signing for the |
| > VSCM under VSCM Designee.                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > ***Note:*** All fields must be completed whenever a withdrawal      |
| > agreement is created.                                               |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > Refer to the following table for filing instructions  |
| Filing and |                                                         |
|  Retention |                                                         |
+------------+---------------------------------------------------------+

  ----------------------- -----------------------------------------------
  If the fiduciary is ... File VA Form 21-8473 on...

  a federal fiduciary,    the left flap.

  court-appointed,        an appropriately designated flap, using the
                          same location (i.e., left, center, or right) in
                          all cases.
  ----------------------- -----------------------------------------------

+-----------------------------------------------------------------------+
| > Retain VA Form 21-8473 for the life of the file.                    |
+-----------------------------------------------------------------------+

#### 22. VA Pamphlet 21-05-1: Federal Fiduciary Program Pocket Folder

+------------+---------------------------------------------------------+
| #####      | > Provide VA Pamphlet 21-05-1 to newly appointed        |
| a. What is | > federal fiduciaries as a convenient place for them to |
|  the purpo | > retain copies of their fiduciary agreement,           |
| se of this | > authorization for allowances, and other pertinent     |
|  pamphlet? | > documents.                                            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b. W | > Give this folder to each individual federal fiduciary |
| hen should | > at the time of certification. Corporate fiduciaries   |
|  this pamp | > recognized as legal custodians, professional          |
| hlet be di | > fiduciaries, and institutions serving as              |
| stributed? | > institutional award payees generally maintain filing  |
|            | > systems and will not find this pamphlet useful.       |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Enter your office local Fiduciary Activity telephone  |
| ### c. Com | > number on the inside right-hand pocket and insert the |
| pletion In | > fiduciary's copy of the Fiduciary Agreement (VA Form  |
| structions | > 21-4703) and any other pertinent documents such as    |
|            | > letters confirming allowances, withdrawal agreement,  |
|            | > etc.                                                  |
+------------+---------------------------------------------------------+