Va Form 24-0296b - Direct Deposit Enrollment (Canada)
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2OMB Approved No. 2900-0564
Respondent Burden: 15 minutes
DIRECT DEPOSIT ENROLLMENT
(CANADA)
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.
Complete Sections 2 and 3. Please be sure to sign your name.
If you want your benefits sent in U.S. dollars to your U.S. dollar account in Canada, ask your financial institution to complete Section 4.
If you want your benefits sent in Canadian dollars to your Canadian dollar account in Canada, ask your financial institution to complete Section 5.
Return the completed form in the envelope provided. Include a VOIDED CHECK to help us code your International Direct Deposit.
SECTION 2
SECTION 1
PAYEE NAME AND MAILING ADDRESS:
NAME OF BANK OR OTHER FINANCIAL INSTITUTION:
ADDRESS OF FINANCIAL INSTITUTION
(Include Area Code)
FINANCIAL INSTITUTION PHONE NUMBER
(Check one)
TYPE OF ACCOUNT
VA CLAIM NUMBER OR VETERAN'S SOCIAL SECURITY NUMBER
U.S. DOLLAR CHECKING
CANADIAN DOLLAR CHECKING
U.S. DOLLAR SAVINGS
CANADIAN DOLLAR SAVINGS
PAYEE NUMBER
(Check one)
OWNERSHIP
JOINT
INDIVIDUAL
SECTION 3 - CERTIFICATIONS
PAYEE CERTIFICATION
JOINT ACCOUNT HOLDER'S CERTIFICATION
I CERTIFY THAT I have read and understand the information on the
I CERTIFY THAT I have read and understand the SPECIAL NOTICE
back of this form. I authorize the Department of Veterans Affairs to
TO JOINT ACCOUNT HOLDERS on the back of this form.
send my payment to my bank for deposit in the designated account.
(Do NOT print)
(Do NOT print)
SIGNATURE OF PAYEE
SIGNATURE OF JOINT ACCOUNT HOLDER
(Month, day, year)
(Month, day, year)
DATE SIGNED
DATE SIGNED
(Include Area Code)
(Include Area Code)
YOUR DAYTIME TELEPHONE NO.
YOUR DAYTIME TELEPHONE NO.
SECTION 4 - TO DEPOSIT U.S. DOLLARS TO YOUR ACCOUNT COMPLETE A OR B BELOW
A. Royal Bank of Canada
B. U.S. dollar account at any other financial institution in Canada
Transit Number
Transit Number
3
0
0
Institution Number
Institution Number
Account Number
Account Number
SECTION 5 - TO DEPOSIT CANADIAN DOLLARS TO YOUR ACCOUNT ASK YOUR BANK TO COMPLETE THIS SECTION
Canadian dollar account at any financial institution in Canada:
Institution Number
Transit Number
Account Number
SECTION 6 - FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As a representative of the above-named financial institution,
I certify that the financial institution agrees to receive and deposit the payment identified above.
PRINT OR TYPE REPRESENTATIVE'S NAME
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
DATE
MAIL THE COMPLETED FORM TO:
FAX THE COMPLETED FORM TO:
Department of Veterans Affairs
Department of Veterans Affairs
FAX Number 1-802-291-6202 or 1-802-291-6299
215 N. Main Street
White River Junction, VT 05001
24-0296B
VA FORM
JUL 2009
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