VA Form 24-0296d EFT Enrollment (Ireland)

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

EFT ENROLLMENT - IRELAND
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 and other pertinent information on the back before completing this form.

SECTION 1 - PAYEE INFORMATION
PAYEE NAME AND MAILING ADDRESS:

SECTION 2 - FINANCIAL INSTITUTION INFORMATION
NAME AND ADDRESS OF FINANCIAL INSTITUTION:

VA CLAIM NUMBER (Required)

PAYEE NUMBER (Required)

VETERAN’S SOCIAL SECURITY NUMBER

FINANCIAL INSTITUTION PHONE NUMBER (Include Country Code)
NAME OF PAYEE (If different from PAYEE above):

IBAN (Must be 22 characters)
SOCIAL SECURITY NUMBER OF BENEFICIARY (If Different From PAYEE Above):

SECTION 3- ACCOUNT INFORMATION
(FUNDS WILL BE DEPOSITED IN LOCAL CURRENCY ONLY)
TYPE OF ACCOUNT (Check one)

ACCOUNT OWNERSHIP (Check one)

CHECKING

INDIVIDUAL ACCOUNT

SAVINGS

JOINT ACCOUNT

SECTION 4 - PAYEE CERTIFICATION
I CERTIFY that I have read and understand the information on
the back of this form. I authorize the Department of Veterans
Affairs to send my payment to my bank for deposit in the
designated account.
SIGNATURE OF PAYEE (Do NOT print)

DATE SIGNED (Month, Day, Year)

PHONE NO. (Include Country Code)

American Embassy
Federal Benefits Unit
Ballsbridge
Dublin 4

24-0296D

I CERTIFY that I have read and understand the SPECIAL
NOTICE TO JOINT ACCOUNT HOLDERS on the back of this
form
SIGNATURE OF JOINT ACCOUNT HOLDER (Do NOT print)

MAIL THE COMPLETED FORM TO:

VA FORM
DEC 2007

SECTION 5 -JOINT ACCOUNT HOLDER’S CERTIFICATION

DATE SIGNED (Month, Day, Year)

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.
TO ENROLL IN A EFT PROGRAM OR CHANGE EXISTING EFT ACCOUNT

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.
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Complete Sections 1, 2, and 3 on the front of this form.
Sign your name in the Signature box under Payee Certification in Section 4.
If you have a joint account, the co-account owner should sign the Joint Account Holder’s Certification, Section 5.

Mail the completed form to the address shown on the front of the form.

CHANGING ACCOUNTS OR CANCELLING EFT

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Notify the American Embassy Federal Benefits Unit immediately if you decide to change or cancel your EFT
account. DO NOT close your old account until your benefits start coming to your new account or home
address. See CONTACT information below.

NOTICE TO JOINT ACCOUNT HOLDERS

.

If you have a joint account and should die, the co-owner of the account should:
1. Notify the American Embassy Federal Benefits Unit or the Department of Veterans Affairs
of your death as soon as possible; and,

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2. Have the financial institution return all Department of Veterans Affairs benefit payments deposited into
the account on your behalf 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 5 on the front of this form.

CONTACT THE OFFICE(S) BELOW FOR ASSISTANCE OR ADDITIONAL INFORMATION

American Embassy
Federal Benefits Unit
Ballsbridge
Dublin 4
Telephone: (353) 1-6688777 (Morning Only)

DEPARTMENT OF VETERANS AFFAIRS
1000 Liberty Avenue
Pittsburgh, PA 15222-4004
Telephone - 00 1 (412) 395-6272
E-mail - https://iris.va.gov

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 Section 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 in order to process payment data from VA to your account at the designated financial institution.
Title 31 Code of Federal Regulations, Section 210.4 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 00 1 (412) 395-6272
or E-mail - https://iris.va.gov to get information on where to send comments or suggestions about this form.