Va Form 24-0296e - Eft Enrollment - United Kingdom
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2OMB Approved No. 2900-0564
Respondent Burden: 15 minutes
EFT ENROLLMENT - UNITED KINGDOM
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 and other pertinent 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)
(Required)
VA CLAIM NUMBER
PAYEE NUMBER
VETERAN'S SOCIAL SECURITY NUMBER
FINANCIAL INSTITUTION PHONE NUMBER (Include Country Code)
(If different from PAYEE above)
NAME OF PAYEE
:
IBAN (Must be 22 characters)
(If Different From PAYEE Above)
SOCIAL SECURITY NUMBER OF BENEFICIARY
:
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 the back
I CERTIFY that I have read and understand the SPECIAL NOTICE TO
of this form. I authorize the Department of Veterans Affairs to send my
JOINT ACCOUNT HOLDERS on the back of this form
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
(Include Country Code)
DATE SIGNED
PHONE NO.
MAIL THE COMPLETED FORM TO:
American Embassy
Federal Benefits Unit
24 Grosvenor Square
London, W1A2LQ, England
24-0296e
VA FORM
JUL 2009
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