FMS 1200 VADE Direct Express

You may also call toll free at 1 (877) 544-6234
(for VA only).

Direct Express® and the Direct Express® logo are registered service marks of the U.S. Department of the Treasury, Financial Management Service.

Sign-Up Form for the Direct Express® Card for Veterans Benefit Payments
DIRECTIONS
Please read the information on page 2 before completing this form. You must complete boxes A, B, C, D and E. Only complete this form to
®
sign up for the Direct Express card if you are an individual who receives VA compensation or pension benefit payments by check. If you currently
receive your payment by direct deposit or if you are a representative payee you may not use this form. Please refer to page 2 for further instructions.

A. FEDERAL BENEFIT RECIPIENT INFORMATION (print name[s] and address exactly as they appear on your benefit check)
NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)
FIRST

MI

LAST

SUFFIX

ADDRESS: STREET 1

STREET 2

CITY

STATE

ZIP CODE

DAYTIME TELEPHONE NUMBER

E-MAIL

SOCIAL SECURITY NUMBER

DATE OF BIRTH OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)
(MM-DD-YYYY)

B. OTHER INFORMATION (if your name or address as it appears on your benefit check is incorrect, please complete this section
with your correct information)
NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)
FIRST

MI

LAST

SUFFIX

ADDRESS: STREET 1

STREET 2

CITY

STATE

ZIP CODE

C. IDENTIFICATION

D. PAYMENT VERIFICATION

VA CLAIM NUMBER

OR
CHECK NUMBER (YOUR MOST RECENT PAYMENT)

In order to process your request, either the claim
number (found on documents from your paying
agency) or the check number from your last
payment (found in the upper right-hand corner
of your Treasury check) must be entered at left.

You must also enter the amount
of your last benefit payment.
AMOUNT OF YOUR MOST RECENT PAYMENT

$

E. CERTIFICATION
I certify that the above information is true, accurate, and complete. I authorize the U.S. Department of the Treasury or its fiscal agent to share the information contained in this
®
document with Treasury's financial agent and the Direct Express® card issuer, Comerica Bank (or its contractors), for the purpose of establishing a Direct Express card account to
be used for the receipt of my Veterans compensation or pension benefit payments. I understand that Comerica Bank issues the Direct Express® card and that the card is subject
to the terms, conditions and fees as described at www.USDirectExpress.com. I authorize the Federal agency that pays my benefits to credit all of my payments to my Direct Express®
card account after it is established. I understand that the Direct Express® card will be mailed to me once my personal information and eligibility to receive benefits have been confirmed.
(See back of form for cancellation information.)

Be sure to complete all sections of this form.
Otherwise, the form cannot be processed.
Return the completed form to:
U.S. Treasury Processing Center
U.S. Department of the Treasury
P.O Box 650527
Dallas, TX 75265-0527

SIGNATURE

DATE

®

This form is only to be used for switching from check payments to a Direct Express card. Use of
this form for any other purposes will result in the form being rejected.
Contact your paying agency to:
Update your name or address
Change your account information if you already receive your payment by direct deposit
FMS Form 1200VADE (April 2010) Previous versions obsolete

OMB No. 1510-0007

PLEASE READ THIS CAREFULLY
ABOUT THE DIRECT EXPRESS® CARD
The Direct Express® Debit MasterCard® card is a prepaid debit card for Social Security, Supplemental Security Income (SSI)
payments and Veterans compensation or pension benefit payments. Cardholders can make purchases, pay bills and get cash at
thousands of locations nationwide. Most services are free. There are fees for a limited number of optional transactions and services.
See www.USDirectExpress.com for details about features and fees. Sign-up is free and no bank account is required.
The Direct Express® Debit MasterCard® is issued by Comerica Bank, pursuant to a license by MasterCard International Incorporated.
MasterCard and the MasterCard brand are registered trademarks of MasterCard International Incorporated.
PRIVACY ACT NOTICE
Your social security number and the other information requested will allow the federal government to make payments to you by
direct deposit to a Direct Express® card account. This collection of information is authorized by Title 31 of the United States Code,
Section 3332(g). Also, Executive Order 9397, November 22, 1943, authorizes the use of your social security number. Your social
security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you
from other recipients of federal payments.
This information will be disclosed to the Department of the Treasury or its agents and their contractors or another disbursing official
to process federal payments to you by direct deposit. This information may also be disclosed to a court, congressional committee or

Please contact your paying agency to:
Update your name or address
Change your account information if you already receive your payment by direct deposit, or
®
If you are a representative payee who wishes to sign up for direct deposit or a Direct Express card

Department of Veterans Affairs
(877) 838-2778
(800) 827-1000
(800) 829-4833 TDD

BURDEN ESTIMATE STATEMENT
The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the
burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information
Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED
FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT
SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.

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