Fillable Va Form 29-0309 - Direct Deposit Enrollment/change printable pdf download

OMB Approved No. 2900-0665

Respondent Burden: 20 minutes

DIRECT DEPOSIT ENROLLMENT/CHANGE

IMPORTANT: You can use this form to enroll in Direct Deposit or to make a change to an existing direct deposit account.

SECTION I - TO BE COMPLETED BY PAYEE

1. NAME AND ADDRESS

2. INSURANCE FILE NUMBER

3. SOCIAL SECURITY NUMBER (Must supply)

4. DAYTIME TELEPHONE NUMBER

(

)

I hereby authorize the Department of Veterans Affairs to start/change direct deposit at the financial institution stated in Item 7, for the

purpose of depositing directly into the account stated in Item 10, any and all Government Life Insurance payments that I am entitled

to receive from all insurance policies under the insurance file number shown in Item 2.

5. SIGNATURE

6. DATE

SECTION II - PLEASE ATTACH A VOIDED PERSONAL CHECK. IF YOU DO, SKIP ITEMS 7-10. IF YOU DO NOT

HAVE A CHECKING ACCOUNT, CONTACT YOUR BANK FOR HELP IN COMPLETING ITEMS 7-10.

NOTE: When a Power of Attorney is applying for Direct Deposit, a copy of a check must be submitted showing the insured’s name

on the account.

7. NAME OF BANK/FINANCIAL INSTITUTION

8. TELEPHONE NUMBER OF BANK/FINANCIAL INSTITUTION

9. BANK ROUTING NUMBER (9 DIGITS)

10. BANK ACCOUNT NUMBER AND TYPE

CHECKING

SAVINGS

Customer Name

Check No. 1234

SAMPLE CHECK

Street Address

The bank routing

The bank account

City, State, ZIP

number is always 9

number varies in length

digits and appears

and may contain dashes

PAY TO THE

between the |:

or spaces. The ||:

ORDER OF

symbols.

symbol indicates the

end of the account

Dollars

number.

|:123456789|:

1617284958569678||:

1234

Bank Routing

Bank Account

Check Number

Number

(Not needed)

11. DO YOU PARTICIPATE IN VAMATIC (AUTOMATIC DEDUCTION OF MONTHLY INSURANCE PREMIUM FROM A CHECKING ACCOUNT)?

IF YES, DOES THIS CHANGE APPLY TO VAMATIC?

YES

MAIL THE COMPLETED FORM TO:

For an Insured:

For a Beneficiary:

VAROIC-DD

P.O. BOX 42954

P.O. BOX 7208

PHILADELPHIA, PA 19101

PHILADELPHIA, PA 19101-7208

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 voluntary, but your failure to provide us the information could

impede processing. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN. 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

responses you submit are considered confidential (38 U.S.C. 5701).

RESPONDENT BURDEN: We need this information to ensure proper transmission of your funds via electronic transfer to your financial institution (31 CFR 208.3 and

210.4). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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 DIRECT DEPOSIT, PLEASE CALL OUR TOLL-FREE NUMBER 1-800-669-8477.

VA FORM

EXISTING STOCKS OF VA FORM 29-0309, AUG 2006,

29-0309

NOV 2009

WILL BE USED.