VA 29-4125 (Claim for One Payment) Fillable Template

Reginfo. gov/public/do/PRAMain. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. IF YOU HAVE QUESTIONS ABOUT THIS FORM PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477 VA FORM MAR 2013 29-4125 SUPERSEDES VA FORM 29-4125 MAR 2010 WHICH WILL NOT BE USED. OMB Approved No* 2900-0060 Respondent Burden 6 Minutes 1. INSURANCE FILE NUMBER CLAIM FOR ONE SUM PAYMENT 2. INSURANCE POLICY NUMBER GOVERNMENT LIFE INSURANCE 4. FIRST MIDDLE LAST NAME OF INSURED VETERAN 3. NET AMOUNT OF INSURANCE 6. BENEFICIARY S SHARE Fraction 5. DATE OF DEATH INSTRUCTIONS WE NEED A PHOTOCOPY OF THE VETERAN S DEATH CERTIFICATE OR A STATEMENT FROM THE ATTENDING PHYSICIAN SHOWING DATE AND CAUSE OF DEATH. ONLY ONE CERTIFICATE OR STATEMENT IS REQUIRED FOR OUR RECORDS* If the beneficiary is a minor or incompetent the person having custody of the beneficiary should complete the form and give his/her address in Item 10. If you are signing as the guardian or attorney-in-fact please include a copy of the court appointment or power of attorney. Send this completed form to Department of Veterans Affairs Regional Office and Insurance Center P. O. Box 7208 Philadelphia PA 19101 NOTE If you prefer instead of mailing this form it may be FAXED to 1-888-748-5822 8. RELATIONSHIP TO INSURED 10A. MAILING ADDRESS MUST BE COMPLETED 9. DATE OF BIRTH OF BENEFICIARY 10B. BENEFICIARY S SOCIAL SECURITY NUMBER 10C. DAYTIME TELEPHONE NUMBER CERTIFICATION I certify that the above entries are true and correct to the best of my knowledge and belief* 11. SIGNATURE OF BENEFICIARY FIDUCIARY OR GUARDIAN 12. DATE U*S* TREASURY MANDATES YOU MUST RECEIVE THIS PAYMENT ELECTRONICALLY. ATTACH A VOIDED CHECK OR COMPLETE BLOCKS A THRU E* THE ACCOUNT MUST BE IN THE NAME OF THE BENEFICIARY. ITEM F MUST BE COMPLETED. IF THE BENEFICIARY IS A TRUST ESTATE OR REPRESENTED BY A FIDUCIARY YOU MUST SEND A VOIDED CHECK FOR THAT SPECIFIC ACCOUNT AND COMPLETE ITEM G* B. ROUTING TRANSIT NUMBER NINE DIGIT FIELD A. NAME OF FINANCIAL INSTITUTION C. TELEPHONE NUMBER OF FINANCIAL INSTITUTION E* DEPOSITOR ACCOUNT NUMBER D. TYPE CHECKING SAVINGS G* EIN OR TIN NUMBER FOR TRUST OR ESTATE ONLY Privacy Act Notice VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1. 576 for routine uses identified in the VA system of records 36VA00 Veterans and Armed Forces Personnel U*S* Government Life Insurance Records-VA and published in the Federal Register. Your obligation to respond is voluntary but your failure to provide us the information could impede processing* Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1 1975 and still in effect.