Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs Page 4

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SECTION XI: DIRECT DEPOSIT INFORMATION

(MUST COMPLETE)

The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit.

Please attach a voided personal check or deposit slip or provide the information requested below in Items 29, 30, and 31 to enroll in direct

deposit. If you do not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct

Express Debit MasterCard you must apply at or by telephone at 1-800-333-1795. If you elect not to enroll, you must

contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will encourage your participation in

EFT and address any questions or concerns you may have.

29. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL

CHECKING

SAVINGS

INSTITUTION OR CERTIFIED PAYMENT AGENT

Account No.:__________________

30. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where

31. ROUTING OR TRANSIT NUMBER (The first nine numbers located

you want your direct deposit)

at the bottom left of your check)

SECTION XII: CLAIM CERTIFICATION AND SIGNATURE

(MUST COMPLETE)

I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I

authorize any person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the Department of

Veterans Affairs any information about me and I waive any privilege which makes the information confidential.

I certify I have received the notice attached to this application titled Notice to Veteran of Evidence Necessary to Substantiate a Claim for

Veterans Non-Service Connected Pension Benefits.

I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal

facility, such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 32,

indicating that I do not want my claim considered for rapid processing in the Fully Developed Claim (FDC) Program because I plan to submit further

evidence in support of my claim.

32. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide the claim. VA will

automatically consider a claim submitted on this form for rapid processing under the FDC Program. Check the below box ONLY if you DO NOT want

your claim considered for rapid processing under the FDC Program because you plan to submit further evidence in support of your claim.

I DO NOT want my claim considered for rapid processing under the FDC Program because I plan to submit further evidence in support of my

claim.

33A. VETERAN'S SIGNATURE (REQUIRED)

33B. DATE SIGNED

SECTION XIII: WITNESSES TO SIGNATURE

(MUST COMPLETE ONLY IF VETERAN SIGNED ITEM 33A WITH AN "X")

34B. PRINTED NAME AND ADDRESS OF WITNESS

34A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

35A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

35B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to pension benefits (38 U.S.C. 5101). The responses you submit are considered

confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is

authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,

and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and

necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with other

agencies. VA may make a "routine use" disclosure for: civil or criminal law enforcement, congressional communications, epidemiological or research

studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA

programs and delivery of VA benefits, verification of identity and status, and personnel administration. Your obligation to respond is required in order to

obtain or retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the

purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in

any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the Social Security

number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may

disclose them for purposes stated above.

RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code, allows us to ask for this

information. We estimate that you will need an average of 25 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

PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-527EZ, JUN 2014

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