Form 24-0296 Direct Deposit Enrollment

OMB Approved No. 2900-0564
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

DIRECT DEPOSIT ENROLLMENT
IMPORTANT: You can use this form to enroll in Direct Deposit or to make a change to an existing direct deposit account.
Please read the Privacy Act and Respondent Burden information shown below.

ATTENTION VA BENEFICIARY!
WE'VE MADE ENROLLING IN DIRECT DEPOSIT EASIER THAN EVER!
CALL TOLL FREE - 1-800-827-1000
or TDD 1-800-829-4833 (Telephone Device for the Hearing Impaired)

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,
58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond
is voluntary. The information solicited under authority of Title 31 Code of Federal
Regulations, Section 210.4 will be used to process the payment data from VA to your
Direct Deposit is the safest, fastest and most cost efficient method to receive your payment. In
account at the designated financial institution. Giving us your Social Security Number
addition, you no longer have to worry about your check being late, lost, or stolen. NOTE: The
"Debt Collection Improvement Act of 1996" which was signed into law on April 26, 1996 required (SSN) is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C.
all Federal payments to be made by Electronic Fund Transfer (EFT or Direct Deposit) beginning 5101 (c) (1). 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
January 1, 1999. Waivers will be available where the conversion from paper checks imposes a
hardship. Write to the address shown below for more information concerning a waiver. To have to January 1, 1975, and still in effect. The requested information is considered relevant
your VA compensation, pension, education, or spina bifida payment deposited into your account and necessary to determine maximum benefits provided by law. The responses you submit
are considered confidential (38 U.S.C. 5701).
right away with Direct Deposit just call VA's toll-free number above or complete this form and
mail to:
Respondent Burden: We need this information to ensure proper transmission of your
Department of Veterans Affairs
funds via electronic transfer to your financial institution (31 CFR 208.3 and 210.4). Title
125 S. Main Street Suite B
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
Muskogee OK 74401-7004
complete this form. VA cannot conduct or sponsor a collection of information unless a
When you call, be sure to have a personal check or bank statement available as well as your VA Claim
valid OMB control number is displayed. You are not required to respond to a collection of
Number or Social Security Number. The VA representative will ask for information from these
information if this number is not displayed. Valid OMB control numbers can be located
documents to start your Direct Deposit. If you prefer to enroll by mail, just complete the information
on the OMB Internet Page at
below, and attach a voided personal check from your checking account or call your Financial Institution
www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
and verify the information requested below for a savings account.
information on where to send comments or suggestions about this form.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

SECTION II: BENEFICIARY'S IDENTIFICATION INFORMATION
5. BENEFICIARY'S NAME (First, Middle Initial, Last - If other than veteran)

6. SOCIAL SECURITY NUMBER

7. VA FILE NUMBER

8. TYPE OF BENEFIT
9. ADDRESS OF PERSON RECEIVING PAYMENT (Check box if new

)

SECTION III: FINANCIAL INSTITUTION INFORMATION
PLEASE ATTACH A VOIDED PERSONAL CHECK AND SKIP TO SECTION III OR CALL YOUR FINANCIAL INSTITUTION FOR THE FOLLOWING
INFORMATION:
10. ROUTING TRANSIT NUMBER

11. ACCOUNT NUMBER (Please check the appropriate box)

CHECKING

SAVINGS

12. NAME OF FINANCIAL INSTITUTION

13. ADDRESS OF FINANCIAL INSTITUTION
14. TELEPHONE NUMBER OF FINANCIAL INSTITUTION (Include Area Code)

SECTION IV: PAYEE CERTIFICATION
I CERTIFY THAT I am entitled to the payment above, and that I have read and understand this form. In signing this form, I authorize my payment to be sent to the
financial institution named above, to be deposited to the designated account.
15. SIGNATURE OF PAYEE (Do NOT print - Sign in ink)

VA FORM
XXXX

24-0296

16. DATE SIGNED

SUPERSEDES VA FORM 24-0296, MAY 2016,
WHICH WILL NOT BE USED.

17. TELEPHONE NUMBER
(Include Area Code)