24-0296A International Direct Deposit Enrollment

OMB Approved No. 2900-0564
Respondent Burden: 15 Minutes
Expiration Date: 02/28/2019

INTERNATIONAL DIRECT DEPOSIT ENROLLMENT
IMPORTANT: PLEASE COMPLETE ALL REQUESTED INFORMATION IN ORDER TO SUCCESSFULLY ENROLL
IN INTERNATIONAL DIRECT DEPOSIT. PLEASE PRINT CLEARLY. BE SURE TO SIGN AND DATE.
A. PERSON TO RECEIVE PAYMENT (Print Clearly)
VETERAN'S NAME

NAME (Last, First, MI)
ADDRESS (Check box if new

)

VETERAN'S SOCIAL SECURITY
NUMBER

VA FILE NUMBER

EMAIL ADDRESS

TELEPHONE NUMBER

B. BANK INFORMATION (Print Clearly)
NAME OF BANK
ADDRESS OF BANK

COUNTRY

BANK CODE

BRANCH CODE

ACCOUNT NUMBER

SWIFT CODE (Required for Euro payments)

IBAN NUMBER (Required for Euro payments)

18 DIGIT CLABE NUMBER (Required for payments to Mexican Banks)

THIS ACCOUNT IS:
MY OWN ACCOUNT

CHECKING

U.S. DOLLARS

A JOINT ACCOUNT

SAVINGS

LOCAL CURRENCY

C. CERTIFICATION
I CERTIFY THAT I am entitled to receive the payment identified above, and that I have read and understand this form. In signing
this form, I authorize this payment to be sent to the financial institution named in Part B above, to be deposited into the account
above.
DATE
SIGNATURE (Sign in ink)
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, 58/VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment
Records - VA, published in the Federal Register. Your obligation to respond is voluntary. The information solicited under the authority of Title 31 Code of Federal Regulations, Section
210.4, will be used to process the payment data from VA to your account at the designated financial institution. Giving us your Social Security Number (SSN) is mandatory. Applicants
are required to provide their SSN under Title 38, U.S.C. 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 to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits
provided by law. The responses you submit are considered confidential (38 U.S.C. 5701).
Respondent Burden: This information is required 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 a 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.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.

MAIL TO: Department of Veterans Affairs
125 S Main Street
Muskogee, OK 74401
E-Mail: DIRECTD.VBAMUS@VA.GOV
Or Fax: (918) 781-7577
VA FORM
JUN 2016

24-0296A

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