Items 1 to 3: names and file number
The name of the fiduciary, the name of the beneficiary and the VA file number, which the form prints with a C- prefix.
21P-4718a
Certificate of Balance on Deposit and Authorization to Disclose Financial Records
- Agency
- VA
- Revision
- October 2024
- Fillable fields
- 47
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21P-4718a: Certificate of Balance on Deposit
VA Form 21P-4718a is the U.S. Department of Veterans Affairs Certificate of Balance on Deposit and Authorization to Disclose Financial Records. A financial institution uses Section I to certify the amounts on deposit to the credit of a fiduciary who manages a VA beneficiary's funds. The fiduciary uses Section II to authorize the institution to verify that certificate to VA and to give VA copies of the financial records described.
The form says VA field examiners use the information to determine whether an individual fiduciary is properly using and maintaining an accounting of the VA beneficiary's compensation or pension payments. The instructions say the fiduciary submits the completed certificate to VA with an accounting.
The form is two pages: the certificate on page 1, then the authorization and the instructions on page 2. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21P-4718a
Items 4A to 5: the financial institution
The institution's name and address, the name and telephone number of its contact person, and the date as of which the account data in Item 6 was accurate.
Item 6: account information
A table with the type of account, account number (state "None" if appropriate), depositor account title, balance including interest earned, interest earned or paid since a date, and the current interest rate.
Items 7A to 7C: certification
The institution certifies that the amounts were on deposit to the credit of the named fiduciary, with the certifying official's signature in ink, title and date, plus the institution's seal or stamp.
Section II: authorization
Item 8 lists what the fiduciary understands, such as the right to withhold consent to the disclosure, then Items 9A and 9B hold the fiduciary's signature in ink and the date.
Notices
The Privacy Act information and a respondent burden of 3 minutes. The form cites Title 38, U.S.C., Chapter 55 and Title 12, U.S.C., Chapter 35.
How VA Form 21P-4718a is completed
- 1
Fiduciary fills Items 1 to 3
Enter the fiduciary's name, the beneficiary's name and the VA file number before handing the form to the financial institution.
- 2
Institution completes Section I
The financial institution fills in Items 4A through 7C, signs in ink and places its seal or stamp in the space provided.
- 3
Fiduciary signs Section II
The fiduciary signs and dates Items 9A and 9B. The instructions say this signature is not needed for the institution to complete the certificate.
- 4
Send it to VA with the accounting
The institution gives the completed certificate to the fiduciary, who submits it to VA with an accounting.
Why fill Form 21P-4718a on indox
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Sending it and what follows
With the accounting
The instructions say the fiduciary submits the certificate to VA with an accounting. The form does not print a mailing address.
Later verification
The form says VA may need an independent verification of financial records when it audits the fiduciary's account. VA then asks the institution directly and gives it the fiduciary's signed authorization.
Not by email
The burden notice names [email protected] for comments on the burden estimate and says not to send the completed VA Form 21P-4718a to that address.
Edition
The OCT 2024 edition supersedes VA Form 21-4718a, DEC 2021, which will not be used. It carries OMB Control No. 2900-0017, which expires 10/31/2027.
Related forms
Who uses VA Form 21P-4718a?
The instructions on page 2 split the form between the fiduciary and the financial institution.
Official sources and the blank
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Questions about Form 21P-4718a
Who fills out VA Form 21P-4718a?
Two parties. The instructions say the fiduciary completes Items 1 to 3 and Section II, and only the financial institution completes Items 4A through 7C of the certificate.
Does the fiduciary have to sign before the bank fills in the certificate?
No. The form says the fiduciary may sign Section II either before or after the financial institution completes the certificate, and that the fiduciary's signature is not needed for the institution to complete it.
Why does VA ask for this form?
The form says VA field examiners use the information to determine whether an individual fiduciary is properly using and maintaining an accounting of the VA beneficiary's compensation or pension payments.
What does the form say about not furnishing the information?
The Privacy Act notice says failure to furnish the requested information may result in the suspension of payments and/or appointment of a successor fiduciary.
Can the old VA Form 21-4718a still be used?
The OCT 2024 edition says it supersedes VA Form 21-4718a, DEC 2021, which will not be used.
Can I email the completed form to VA?
The form says not to send the completed VA Form 21P-4718a to the VA Reports Clearance Officer email address, which is for comments on the burden estimate. The instructions say it goes to VA with an accounting.