Fillable Printable Direct Deposit Enrollment - Department of Veterans Affairs

Direct Deposit Enrollment - Department of Veterans Affairs

OMB Approved No. 2900-0564

Respondent Burden: 15 minutes

DIRECT DEPOSIT ENROLLMENT

IMPORTANT: You can use this form to enroll in Direct Deposit or to make a change to an existing direct deposit

account. Please read the Privacy Act and Respondent Burden information shown below.

ATTENTION VA BENEFICIARY!

WE'VE MADE ENROLLING IN DIRECT DEPOSIT EASIER THAN EVER!

CALL TOLL FREE - 1-877-838-2778

or TDD 1-800-829-4833 (Telephone Device for the Hearing Impaired)

Direct Deposit is the safest, fastest and most cost efficient method to receive your payment. In addition, you no longer

have to worry about your check being late, lost, or stolen. NOTE: The "Debt Collection Improvement Act of 1996" which

was signed into law on April 26, 1996 required all Federal payments to be made by Electronic Fund Transfer (EFT or

Direct Deposit) beginning January 1, 1999. Waivers will be available where the conversion from paper checks imposes a

hardship. Write to the address shown below for more information concerning a waiver. To have your VA compensation,

pension, education, or spina bifida payment deposited into your account right away with Direct Deposit just call VA's toll-

free number above or complete this form and mail to:

When you call, be sure to have a personal check or bank statement available as well as your VA Claim Number or Social Security Number. The VA

representative will ask for information from these documents to start your Direct Deposit. If you prefer to enroll by mail, just complete the information

below, and attach a voided personal check from your checking account or call your Financial Institution and verify the information requested below for a

savings account.

SECTION I - VA BENEFICIARY INFORMATION

NAME OF BENEFICIARY (Last, First, MI) (Please Print)

BENEFICIARY CLAIM NUMBER

TYPE OF BENEFIT

VA CLAIM NUMBER OR SOCIAL SECURITY NUMBER

TELEPHONE NUMBER (PLEASE PROVIDE YOUR TELEPHONE NUMBER IN THE EVENT THAT WE NEED TO CONTACT YOU) (INCLUDE AREA CODE)

DAYTIME TELEPHONE NUMBER

SECTION II - FINANCIAL INSTITUTION INFORMATION

PLEASE ATTACH A VOIDED PERSONAL CHECK AND SKIP TO SECTION III OR CALL YOUR FINANCIAL

INSTITUTION FOR THE FOLLOWING INFORMATION:

ROUTING TRANSIT NUMBER

ACCOUNT NUMBER (PLEASE CHECK THE APPROPRIATE BOX

NAME OF FINANCIAL INSTITUTION

ADDRESS OF FINANCIAL INSTITUTION

TELEPHONE NUMBER OF FINANCIAL INSTITUTION

(Include Area Code)

SECTION III - PAYEE CERTIFICATION

I CERTIFY THAT I am entitled to the payment above, and that I have read and understand this form. In signing this form, I authorize my payment to

be sent to the financial institution named above, to be deposited to the designated account.

DATE SIGNED

SIGNATURE OF PAYEE

(Do NOT print)

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 as identified in the VA system of records, 58VA21/22/28, Compensation, Pension,

Education, Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. An example of a routine use is that the information

will be used to process the payment data from VA to the beneficiary's designated financial institution. Your obligation to respond is voluntary.

Respondent Burden: We need this information to ensure proper transmission of your funds via electronic transfer to your financial institution (31 CFR

208.3 and 210.4). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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 www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to

send comments or suggestions about this form.

VA FORM

NOV 2009

24-0296

SUPERSEDES VA FORM 24-0296, FEB 2006,

WHICH WILL NOT BE USED.

EVENING TELEPHONE NUMBER

COMPENSATION PENSION EDUCATION (CHAPTERS 30, 33, 1606,1607 & National Call to Service) CHAPTER 18

CHAPTER 31

Department of Veterans Affairs

125 S. Main Street Suite B

Muskogee OK 74401-7004

SAVINGS)CHECKING