Fillable Claim For One Sum Payment - Veterans Benefits Administration printable pdf download

OMB Approved No. 2900-0060

Respondent Burden: 6 Minutes

Expiration Date: 12/31/2019

1. INSURANCE FILE NUMBER

CLAIM FOR ONE SUM PAYMENT

2. INSURANCE POLICY NUMBER

GOVERNMENT LIFE INSURANCE

3. NET AMOUNT OF INSURANCE

4. FIRST, MIDDLE, LAST NAME OF INSURED VETERAN

5. DATE OF DEATH

6. BENEFICIARY'S SHARE (Fraction)

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.

MAIL:

FAX:

This completed form may be submitted by:

VA Insurance Center

1-888-748-5822

P.O. Box 7208

Philadelphia, PA 19101

7. FIRST, MIDDLE AND LAST NAME OF BENEFICIARY (Please print)

8. RELATIONSHIP TO INSURED

9. DATE OF BIRTH OF BENEFICIARY

10A. MAILING ADDRESS (MUST BE COMPLETED)

10B. BENEFICIARY'S SOCIAL SECURITY NUMBER

10C. EMAIL ADDRESS

10D. 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.

A. NAME OF FINANCIAL INSTITUTION

B. ROUTING TRANSIT NUMBER (NINE DIGIT FIELD)

C. TELEPHONE NUMBER OF FINANCIAL INSTITUTION

D. TYPE

E. DEPOSITOR ACCOUNT NUMBER

CHECKING

SAVINGS

F. BENEFICIARY'S SOCIAL SECURITY NUMBER (Required for Direct Deposit)

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.

Respondent Burden: We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 5902). Title 38, United States Code, allows us to ask for

this information. We estimate that you will need an average of 6 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of

information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be

located on the OMB Internet Page at 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

29-4125

SUPERSEDES VA FORM 29-4125, MAR 2013,

PAGE 1

DEC 2016

WHICH WILL NOT BE USED.