Form VA Form 29-0165 VA Form 29-0165 VA MATIC Enrollment/Change

OMB Approved No. 2900-0525
Respondent Burden: 15 minutes

VA MATIC ENROLLMENT/CHANGE
IMPORTANT: You can use this form to enroll in VA MATIC or to make a change to an existing account.
SECTION I - TO BE COMPLETED BY INSURED
1. NAME AND ADDRESS OF INSURED

2. INSURANCE FILE NUMBER

3. SOCIAL SECURITY NUMBER

4. DAYTIME TELEPHONE NUMBER

(
)
I HEREBY authorize the Department of Veterans Affairs to start/change a deduction from my account at the financial institution
stated below for the purpose of paying Government Life Insurance premiums. I further authorize the Department of Veterans Affairs
to adjust the amount of this deduction if my premiums increase or decrease. I understand that each deduction will be in the amount of
my monthly premium payment and the deduction shall be made on the premium due date. Unless otherwise specified by me, this
authorization will cover all of the Government Life Insurance policies under the insurance file number shown in Item 2.
5. SIGNATURE OF INSURED

6. DATE SIGNED

SECTION I I - PLEASE ATTACH A VOIDED PERSONAL CHECK. IF YOU DO, SKIP BLOCKS 7-10.
7. NAME OF BANK/FINANCIAL INSTITUTION

8. PHONE NUMBER OF BANK/FINANCIAL INSTITUTION

9. BANK ROUTING NUMBER (9 DIGITS)

10. CHECKING ACCOUNT NUMBER

Customer Name
Street Address
City, State, ZIP
The bank routing
number is always 9
digits and appears
between the :
symbols.

Check No. 1234
SAMPLE CHECK
$

PAY TO THE
ORDER OF

Dollars

: 123456789 :
Bank Routing
Number

1617284958569678
Bank Account
Number

The bank account
number varies in length
and may contain dashes
or spaces. The symbol
indicates the end of the
account number.

1234
Check Number
(Not Needed)

MAIL THE COMPLETED FORM TO:
VAROIC
P.O. BOX 42954
PHILADELPHIA, PA 19101
PRIVACY ACT NOTICE: The 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 5, Code of Federal Regulations 1.526 for routine uses identified in the VA system of records, 36VA00 , Veterans and Armed Forces Personnel U..S.
Government Life Insurance Records - VA, 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 social security number account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of
benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in
effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 US 5701).
RESPONDENT BURDEN: No insurance deduction may be made unless a completed authorization is received (38 US 708). We estimate that you will need an average
of 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/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.

IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE, PLEASE CALL OUR TOLL-FREE NUMBER 1-800-669-8477.
VA FORM
JUN 2006

29-0165

EXISTING STOCK OF VA FORM 29-0165, JAN 1999,
WILL BE USED.