U.S. DOD Form dod-va-4012
IN THE
COURT OF
NO.
CERTIFICATE OF INCOMPETENCY
THIS WILL CERTIFY THAT
is a beneficiary of the Department of Veterans Affairs (VA); that the beneficiary has been rated incompetent by VA
on examination dated
, 19
, in accordance with the laws and regulations
governing VA, and that the appointment of a
is a condition precedent to the payment of moneys due the beneficiary
by VA.
THAT the undersigned has been duly authorized by the Secretary of Veterans Affairs to execute this
certificate which has been issued pursuant to the provisions of
Dated this
day of
Signature:
Title:
Office:
VA FORM
MAR 1991
2-4012
, 19
.