OMB Approved No. 2900-0564
Respondent Burden: 15 Minutes
Expiration Date: 02/28/2019
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. Your obligation to respond is voluntary. The information solicited under authority of Title 31 Code of Federal
Regulations, Section 210.4 will ne used to process the payment data from VA to your account at the designated financial institution. Giving us your Social Security Number
(SSN) is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. 5101 (c) (1). 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. The requested information is considered relevant and
necessary to determine maximum benefits provided by law. The responses you submit are considered confidential (38 U.S.C. 5701).
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 form.
VA FORM
MAY 2016
24-0296
SUPERSEDES VA FORM 24-0296, NOV 2009,
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
