OMB Approved No. 2900-0564
Respondent Burden: 15 Minutes
Expiration Date: 08/31/2022
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.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
ATTENTION VA BENEFICIARY!
WE'VE MADE ENROLLING IN DIRECT DEPOSIT EASIER THAN EVER!
CALL TOLL FREE - 1-800-827-1000 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:
Department of Veterans Affairs
125 S. Main Street Suite B
Muskogee OK 74401-7004
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.
8. TYPE OF BENEFIT
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER 3. VA FILE NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
5. BENEFICIARY'S NAME (First, Middle Initial, Last - If other than veteran)
6. SOCIAL SECURITY NUMBER 7. VA FILE NUMBER
SECTION II: BENEFICIARY'S IDENTIFICATION INFORMATION
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
SECTION IV: 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.
15. SIGNATURE OF PAYEE (Do NOT print - Sign in ink)
17. TELEPHONE NUMBER (Include Area Code)
16. DATE SIGNED
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside
VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.
Information submitted is subject to verification through computer matching programs with other agencies. VA may make a “routine use” disclosure for: civil or criminal law enforcement,
congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the
administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration. Your obligation to respond is required in order to obtain or retain
benefits (31 CFR 208.3 and 210.4). Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of determining your eligibility to
receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs. Social
Security information: You are required to provide the Social Security number requested under 38 U.S.C. 5101( c) (1) . VA may disclose Social Security numbers as authorized under the Privacy Act,
and, specifically may disclose them for purposes stated above.
SUPERSEDES VA FORM 24-0296, MAR 2018,
WHICH WILL NOT BE USED.
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.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
SECTION III: FINANCIAL INSTITUTION INFORMATION
PLEASE ATTACH A VOIDED PERSONAL CHECK AND SKIP TO SECTION III OR CALL YOUR FINANCIAL INSTITUTION FOR THE FOLLOWING INFORMATION:
10. ROUTING TRANSIT NUMBER
11. ACCOUNT NUMBER (Please check the appropriate box) SAVINGS
12. NAME OF FINANCIAL INSTITUTION
14. TELEPHONE NUMBER OF FINANCIAL INSTITUTION (Include Area Code)
13. ADDRESS OF FINANCIAL INSTITUTION
9. ADDRESS OF PERSON RECEIVING PAYMENT (Check box if new )