Va Form 24-0296c - Eft Enrollment - Germany
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2OMB Approved No. 2900-0564
Respondent Burden: 15 minutes
EFT ENROLLMENT - GERMANY
IMPORTANT: Use this form to enroll in Direct Deposit (EFT) or to change information for an existing EFT account. Please read the Privacy
Act Notice and Respondent Burden information on the back before completing this form.
SECTION 1 - PAYEE INFORMATION
SECTION 2 - FINANCIAL INSTITUTION INFORMATION
PAYEE NAME AND MAILING ADDRESS:
NAME AND ADDRESS OF FINANCIAL INSTITUTION:
(Required)
VA CLAIM NUMBER
(Required)
PAYEE NUMBER
(Include Country Code)
FINANCIAL INSTITUTION PHONE NUMBER
VETERAN'S SOCIAL SECURITY NUMBER
(If different from PAYEE above):
NAME OF PAYEE
(Must be 22 characters)
IBAN
SOCIAL SECURITY NUMBER OF BENEFICIARY
(If different from PAYEE above):
SECTION 3 - ACCOUNT INFORMATION
(FUNDS WILL BE DEPOSITED IN LOCAL CURRENCY ONLY)
(Check one)
(Check one)
TYPE OF ACCOUNT
ACCOUNT OWNERSHIP
CHECKING
INDIVIDUAL ACCOUNT
SAVINGS
JOINT ACCOUNT
SECTION 4 - PAYEE CERTIFICATION
SECTION 5 - JOINT ACCOUNT HOLDER'S CERTIFICATION
I CERTIFY that I have read and understand the information on
I CERTIFY that I have read and understand the SPECIAL
the back of this form. I authorize the Department of Veterans
NOTICE TO JOINT ACCOUNT HOLDERS on the back of this
Affairs to send my payment to my bank for deposit in the
form
designated account.
(Do NOT print)
(Do NOT print)
SIGNATURE OF PAYEE
SIGNATURE OF JOINT ACCOUNT HOLDER
(Month, Day, Year)
PHONE NO.
(Month, Day, Year)
DATE SIGNED
DATE SIGNED
(Include Country Code)
MAIL THE COMPLETED FORM TO:
American Consulate General
Federal Benefits Unit
Giessener Strasse 30
60435 Frankfurt/Main
24-0296C
VA FORM
JUL 2009
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