Fillable Printable Request for Change of Address / Cancellation of Direct Deposit

Request for Change of Address / Cancellation of Direct Deposit

If your benefit payment is currently being sent to a financial organization, but you want it cancelled and sent to your home address, check this box.

Your payments will continue to be sent to the financial organization until the cancellation is processed. DO NOT close your bank account

until your first payment is received at your home address.

REQUEST FOR CHANGE OF ADDRESS/CANCELLATION OF DIRECT DEPOSIT

NOTE: To notify the Department of Veterans Affairs of a change in address, cancellation of direct deposit, or both, complete this form and

mail it to the VA office having your records. The information is requested under Title 38, United States Code, and will help insure that VA

correspondence and any VA benefit checks to which you may be entitled are sent to your correct address. Disclosure is voluntary. However,

if the information is not furnished, your mail may be lost or delayed and benefit payments, if any, may be suspended. Failure to furnish this

information will have no other adverse effect on any benefit to which you may be entitled. The information may be disclosed outside VA as

permitted by law, or as stated in the “Notices of Systems of VA Records” which have been published in the Federal Register in accordance

with the Privacy Act of 1974.

EDUCATION

SUPERSEDES VA FORM 572, OCT 1993,

WHICH WILL NOT BE USED.

3. VA FILE NO. (Include letter prefix, if any)

4. VETERAN'S SOCIAL SECURITY NO.

11. NEW ADDRESS (Check only if applicable)

1. I AM REQUESTING (Check appropriate box) 2. I AM RECEIVING BENEFITS AS THE (Check appropriate box)

A CHANGE OF MY RESIDENCE ADDRESS BOTH

FATHER

MOTHER

A CANCELLATION OF MY DIRECT

DEPOSIT ACCOUNT

5. PAYEE NO. (Type or print)

6. BENEFIT TYPE (Check the benefit or benefits affected)

7. INSURANCE NO(S) (Only give these numbers if you are receiving payments on the

insurance policy of a deceased veteran)

8. TYPE OF ADDRESS CHANGE (Complete if applicable)

9. NAME OF PAYEE AS SHOWN ON CHECK (Type or print)

10. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN

CITY STATE ZIP CODE

14. DATE

PERMANENT TEMPORARY

COMPENSATION OR

PENSION

CHAPTER 30

(Montgomery G.I. Bill-Active)

CHAPTER 31

(Voc. Rehab.)

CHAPTER 32 (VEAP)

CHAPTER 35 (DEA)

CHAPTER 1606

(Montgomery G.I. Bill-Reserve)

CHILD

OTHER

(Specify)

SURVIVING SPOUSEWIFE/HUSBAND

FIDUCIARY

VETERAN

OTHER (Specify)

NUMBER AND STREET OR RURAL ROUTE (Include Apartment Number if appropriate) TELEPHONE NUMBER (Include Area Code)

DAYTIME EVENING

12. TO BE COMPLETED BY DIRECT DEPOSIT PARTICIPANTS ONLY

13. SIGNATURE OF VETERAN OR PAYEE (Do not print)

20-572

VA FORM

MAR 1996