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

In Reply Refer to:

File Number:

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 in Item 8 below.
OMB Approved No.: 2900-0635
Respondent Burden: 10 minutes
Expiration Date: XXXXXXXXXX

NOTE - 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 NO.

5. DAYTIME TELEPHONE NUMBER (Include Area Code)

C. CHECKING OR SAVINGS ACCOUNT NUMBER

D. TYPE OF ACCOUNT
CHECKING

6. SIGNATURE (DO NOT PRINT)

7. DATE SIGNED

SAVINGS
8. DATE OF DEATH (If Payee is deceased)

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 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 obtain this benefit. Giving us your SSN
account information is voluntary. Refusal to provide your SSN by itself will not result in the 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 to continue your payment of a monthly 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 the form. VA cannot conduct
or sponsor a collection of information unless a valid OMB control number is 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.

Please return this completed 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/his own affairs, please call the toll-free number below.
Questions about your insurance? Call us toll-free at 1-800-699-8477. The best days to call are Wednesday and Thursday.
Operators are on duty Monday through Friday 8:30 AM to 6:00 PM Eastern Time.
VA FORM
XXX 2014

29-0759

SUPERSEDES VA FORM 29-0759, OCT 2008,
WHICH WILL NOT BE USED.