Form VA Form 24-0296a VA Form 24-0296a Direct Deposit Enrollment (Australia)

OMB Approved No. 2900-0564
Respondent Burden: 15 minutes

DIRECT DEPOSIT ENROLLMENT
(AUSTRALIA)
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
WHICH COUNTRY DO YOU LIVE IN:
Note: Please read the Important Information on the back before completing this form.

SECTION 1 (Payee Information)
PAYEE NAME AND MAILING ADDRESS:

SECTION 2 (To Be Completed By Payee Or Financial
Institution Representative)
NAME OF BANK OR OTHER FINANCIAL INSTITUTION:

ADDRESS OF FINANCIAL INSTITUTION

FINANCIAL INSTITUTION PHONE NUMBER (Include Area Code)

VA CLAIM NUMBER OR VETERAN’S SOCIAL SECURITY NUMBER

TYPE OF ACCOUNT (Check one)

OWNERSHIP (Check one)

CHECKING

INDIVIDUAL ACCOUNT

SAVINGS

JOINT ACCOUNT

PAYEE NUMBER

SECTION 3 - CERTIFICATIONS
JOINT ACCOUNT HOLDER’S CERTIFICATION

PAYEE CERTIFICATION
I CERTIFY THAT I have read and understand the information on the
back of this form. I authorize the Department of Veterans Affairs to
send my payment to my bank for deposit in the designated account.

I CERTIFY THAT I have read and understand the SPECIAL NOTICE TO
JOINT ACCOUNT HOLDERS on the back of this form.

SIGNATURE OF PAYEE (Do NOT print)

SIGNATURE OF JOINT ACCOUNT HOLDER (Do NOT print)

DATE SIGNED (Month, day, year)

PHONE NO. (Include Area Code)

DATE SIGNED (Month, day, year)

SECTION 4 - FINANCIAL INSTITUTION INFORMATION (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
ACCOUNT
NUMBER
TRANSIT NUMBER
INSTITUTION NUMBER
BSB OR SORTING CODE
NUMBER
SECTION 5 - 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

MAIL THE COMPLETED FORM TO:
Automated Payments - 1st Floor
Federal Reserve Bank of New York,
East Rutherford Operations Center
100 Orchard Street
East Rutherford, NJ 07073
VA FORM
FEB 2006

24-0296A

TELEPHONE NUMBER

DATE

IMPORTANT INFORMATION - PLEASE READ CAREFULLY
The Debt Collection Improvement Act of 1996, which was signed into law on April 26, 1996, required all
Federal payments to be made by electronic fund transfer (EFT) beginning on January 1, 1999. The EFT
requirement can be waived in situations where converting to EFT will impose an undue hardship. For more
information about waivers, please contact the VA Regional Office shown below.
HOW TO ENROLL IN EFT PROGRAM OR CHANGE EXISTING EFT ACCOUNT

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You or a representative of your financial institution must complete Sections 2 and 4 on the front of this form.
You must sign your name in the signature box under the Payee Certification Statement in Section 3. If a
representative of the financial institution completes this form he or she should sign Section 5.
Mail the completed form, along with a voided check if possible, in the envelope provided.

CHANGING ACCOUNTS OR FINANCIAL INSTITUTIONS

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You must notify the Department of Veterans Affairs immediately if you change your account information and/or your
financial institution. DO NOT close your old account until your benefits start coming to
your new account.

NOTICE TO JOINT ACCOUNT HOLDERS

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If you have a joint account and should die, the co-owner of the account should:
1. Notify the Department of Veterans Affairs of your death as soon as possible
2. Return to the Department of Veteran Affairs all benefit payments deposited into the account
after the date of your death.
The co-owner of the account should acknowledge that he/she is aware of these requirements by signing the Joint
Account Certification in Section 3 on the front of this form.

IF YOU HAVE ANY EFT ENROLLMENT QUESTIONS, CONTACT THE OFFICE BELOW:

DEPARTMENT OF VETERANS AFFAIRS
VA Regional Office
Foreign Claims
1000 Liberty Avenue
Pittsburgh, PA 15222-4004
Telephone - (412) 395-6272
E-mail - vavbapit/ro/[email protected]
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, Section 1.576, for routine uses as identified in the VA system of records 58VA21/22,
Compensation, Pension, Education and Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. The
information, solicited under the authority of Title 31 Code of Federal Regulations, Section 210.4, will be used to process the payment data from VA to
your account at the designated financial institution.

RESPONDENT BURDEN: This information is required in order to process payment data from VA to your account at the designated financial institution.
Title 31 Code of Federal Regulations, Section 210.4, allows us to ask for this information. We estimate that you will need an average 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 www.whitehouse.gov.omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.