VA Form 24-0296b Direct Deposit Enrollment (Canada)

OMB Approved No. 2900-0564
Respondent Burden: 15 minutes

DIRECT DEPOSIT ENROLLMENT
(CANADA)
IMPORTANT: Use this form to enroll in Direct Deposit (EFT) or to change information for an existing EFT account.
Please read the Privacy Act Notice and Respondent Burden information on the back before completing this form.

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Complete Sections 2 and 3. Please be sure to sign your name.
If you want your benefits sent in U.S. dollars to your U.S. dollar account in Canada, ask your financial institution to complete Section 4.
If you want your benefits sent in Canadian dollars to your Canadian dollar account in Canada, ask your financial institution to complete Section 5.
Return the completed form in the envelope provided. Include a VOIDED CHECK to help us code your International Direct Deposit.

SECTION 2

SECTION 1
PAYEE NAME AND MAILING ADDRESS:

NAME OF BANK OR OTHER FINANCIAL INSTITUTION:

ADDRESS OF FINANCIAL INSTITUTION

FINANCIAL INSTITUTION PHONE NUMBER (Include Area Code)
VA CLAIM NUMBER OR VETERAN’S SOCIAL SECURITY NUMBER

TYPE OF ACCOUNT (Check one)
U.S. DOLLAR CHECKING
U.S. DOLLAR SAVINGS
OWNERSHIP (Check one)

PAYEE NUMBER

CANADIAN DOLLAR CHECKING
CANADIAN DOLLAR SAVINGS

SECTION 3 - CERTIFICATIONS
PAYEE CERTIFICATION

JOINT ACCOUNT HOLDER’S CERTIFICATION

I CERTIFY THAT I have read and understand the information on the

I CERTIFY THAT I have read and understand the SPECIAL NOTICE TO JOINT

back of this form. I authorize the Department of Veterans Affairs to

ACCOUNT HOLDERS on the back of this form.

send my payment to my bank for deposit in the designated account.
SIGNATURE OF PAYEE (Do NOT print)

SIGNATURE OF JOINT ACCOUNT HOLDER (Do NOT print)

DATE SIGNED (Month, day, year)

DATE SIGNED (Month, day, year)

YOUR DAYTIME TELEPHONE NO. (Include Area Code)

YOUR DAYTIME TELEPHONE NO. (Include Area Code)

SECTION 4 - TO DEPOSIT U.S. DOLLARS TO YOUR ACCOUNT COMPLETE A OR B BELOW
A. Transit Number
(5 digits begins with 0)
Institution Number

B. U.S. dollar account at any other financial institution in Canada
Transit Number

0

0

3

Institution Number

Account Number
(Must be 7 digits, begins with 4 or 8, no dash)

Account Number

SECTION 5 - TO DEPOSIT CANADIAN DOLLARS TO YOUR ACCOUNT ASK YOUR BANK TO COMPLETE THIS SECTION
Canadian dollar account at any financial institution in Canada:
Transit Number

Institution Number

Account Number

SECTION 6 - FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As a representative of the above-named financial institution,
I certify that the financial institution agrees to receive and deposit the payment identified above.
PRINT OR TYPE REPRESENTATIVE’S NAME

SIGNATURE OF REPRESENTATIVE

MAIL THE COMPLETED FORM TO:
Department of Veterans Affairs
215 N. Main Street
White River Junction, VT 05001
VA FORM
FEB 2006

24-0296B

TELEPHONE NUMBER

FAX THE COMPLETED FORM TO:
Department of Veterans Affairs
FAX Number 1-802-291-6202 or 1-802-291-6299

DATE

IMPORTANT INFORMATION - PLEASE READ CAREFULLY
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) beginning on January 1, 1999. The EFT
requirement can be waived in situations where converting to EFT will impose an undue hardship. For more
information about waivers, please contact the VA Regional Office shown below.
HOW TO ENROLL IN EFT PROGRAM OR CHANGE EXISTING EFT ACCOUNT

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You or a representative of your financial institution must complete Sections 2 and 4 on the front of this form.
You must sign your name in the signature box under the Payee Certification Statement in Section 3. If a
representative of the financial institution completes this form he or she should sign Section 5.
Mail the completed form, along with a voided check if possible, in the envelope provided.

CHANGING ACCOUNTS OR FINANCIAL INSTITUTIONS

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You must notify the Department of Veterans Affairs immediately if you change your account information and/or your
financial institution. DO NOT close your old account until your benefits start coming to
your new account.

NOTICE TO JOINT ACCOUNT HOLDERS

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If you have a joint account and should die, the co-owner of the account should:
1. Notify the Department of Veterans Affairs of your death as soon as possible
2. Return to the Department of Veteran Affairs all benefit payments deposited into the account
after the date of your death.
The co-owner of the account should acknowledge that he/she is aware of these requirements by signing the Joint
Account Certification in Section 3 on the front of this form.

IF YOU HAVE ANY EFT ENROLLMENT QUESTIONS, CONTACT THE OFFICE BELOW:

DEPARTMENT OF VETERANS AFFAIRS
VA Regional Office
215 N. Main Street
White River Junction, VT 05001
Telephone - 1-802- 295-9363 EXT. 5177

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, Compensation,
Pension, Education and Rehabilitation Records - VA, and 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 (title
31 C.F.R. 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.