Form VA Form 29-0759 VA Form 29-0759 Suspension of Monthly Check

IN REPLY REFER TO:

FILE NUMBER:
P.O. BOX 7208
PHILA., PA 19101-7208

Dear Policyholder:
We have suspended payment of your monthly insurance checks. The Department of the Treasury has informed us that
your
check was not cashed within one year from the issue date. They have cancelled the check
and forwarded the funds to us. If you still have that check, please destroy it. You must complete and return this letter before
we can take further action.
The check was returned because
(If the payee is deceased, please provide the date of death)
OMB Approved No. 2900-0635
Respondent Burden: 10 minutes
Please complete the items below. Only complete Item 2 if you desire Direct Deposit.
1. HOME ADDRESS

2. U.S. BANK ACCOUNT
A. BANK NAME

B. TRANSIT/ROUTING NUMBER

3. DATE OF BIRTH

4. SOCIAL SECURITY NUMBER

5. DAYTIME TELEPHONE NUMBER (Including Area Code)

(

)

C. CHECKING OR SAVINGS ACCOUNT NUBMER

6. EVENING TELEPHONE NUMBER (Including Area Code)

(

7. SIGNATURE (Do NOT print)

)

8. DATE

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 Regualtions 1.576 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel
U.S. Government Life Insurance Records - VA, and published in the Federal Register. Your obligation to respond is required to retain benefits. Giving us your
SSN account information is voluntary. Refusal to provide your SSN by itself will not result in denial of benefits. 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.
RESPONDENT BURDEN: We need this information from you to resume payment of your monthly government life insurance check. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 10 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.

Please return this form to:
Department of Veterans Affairs
P.O. Box 7208
Philadelphia, PA 19101-7208
If you have any questions or if the payee is incapable of conducting his/her own affairs, please call the toll free number below.
QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL-FREE AT 1-800-669-8477 THE BEST DAYS TO CALL ARE WEDNESDAY AND THURSDAY
OPERATORS ARE ON DUTY
MONDAY THROUGH FRIDAY 8:30AM TO 6:00 PM EASTERN TIME
VA FORM
MAY 2008

29-0759

EXISTING STOCKS OF VA FORM 29-0759, JAN 2003,
WILL BE USED.