Fillable Va Form 29-0165 - Va Matic Enrollment/change printable pdf download

OMB Approved No. 2900-0525

Respondent Burden: 15 minutes

VA MATIC ENROLLMENT/CHANGE

IMPORTANT: You can use this form to enroll in VA MATIC or to make a change to an existing account.

SECTION I - TO BE COMPLETED BY INSURED

1. NAME AND ADDRESS OF INSURED

2. INSURANCE FILE NUMBER

3. SOCIAL SECURITY NUMBER

4. DAYTIME TELEPHONE NUMBER

I HEREBY authorize the Department of Veterans Affairs to start/change a deduction from my account at the financial institution

stated below for the purpose of paying Government Life Insurance premiums. I further authorize the Department of Veterans Affairs

to adjust the amount of this deduction if my premiums increase or decrease. I understand that each deduction will be in the amount of

my monthly premium payment and the deduction shall be made on the premium due date. Unless otherwise specified by me, this

authorization will cover all of the Government Life Insurance policies under the insurance file number shown in Item 2.

5. SIGNATURE OF INSURED

6. DATE

SECTION I I - PLEASE ATTACH A VOIDED PERSONAL CHECK. IF YOU DO, SKIP BLOCKS 7-10.

7. NAME OF BANK/FINANCIAL INSTITUTION

8. PHONE NUMBER OF BANK/FINANCIAL INSTITUTION

(9 DIGITS)

10. CHECKING ACCOUNT NUMBER

9. BANK ROUTING NUMBER

Customer Name

Check No. 1234

The bank account

Street Address

SAMPLE CHECK

number varies in length

City, State, ZIP

and may contain dashes

The bank routing

PAY TO THE

or spaces. The symbol

number is always 9

ORDER OF

indicates the end of the

Dollars

digits and appears

account number.

between the :

symbols.

: 123456789 :

1234

1617284958569678

Bank Routing

Bank Account

Check Number

Number

(Not Needed)

11. DO YOU PARTICIPATE IN DIRECT DEPOSIT? IF YES, WILL THIS NEW INFORMATION APPLY TO DIRECT DEPOSIT?

YES

MAIL THE COMPLETED FORM TO:

VAROIC

P.O. BOX 42954

PHILADELPHIA, PA 19101

PRIVACY ACT NOTICE: The 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 5, Code of Federal Regulations 1.526 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S.

Government Life Insurance Records - VA, published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information

could impede processing. Giving us your social security number account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of

benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in

effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 USC 5701).

RESPONDENT BURDEN: No insurance deduction may be made unless a completed authorization is received (38 USC 708). We estimate that you will need an

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 If desired, you can call 1-800-827-1000 to get information on where to send

comments or suggestions about this form.

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, PLEASE CALL OUR TOLL-FREE NUMBER 1-800-669-8477.

VA FORM

EXISTING STOCK OF VA FORM 29-0165, JUN 2006,

29-0165

JUN 2007

WILL BE USED.