VA Form 22-8794a Designated Certifying Official(s) Electronic Fund Transf

OMB Approved No. 2900-0262
Respondent Burden: 10 Minutes

DESIGNATED CERTIFYING OFFICIAL(S) ELECTRONIC FUND TRANSFER (EFT) INFORMATION
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 1.576 for routine uses as identified in the VA system of records 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation Records - VA, and
published in the Federal Register. Your obligation to respond is voluntary. This form is provided to help ease the cost and increase the security for financial transactions that may occur due to
chapter 33 (Public Law 110-252) by using electronic fund transfers. The responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants,
recipients, and others is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to identify that you, as the certifying official for your school or job training establishment, request electronic fund transfer for your school
or learning institution. We estimate that you will need an average of 10 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/omb/OMBINV.VA.EPA.html#VA. If desired, you can call 1-888-GI-BILL-1 (1-888-442-4551) to get
information on where to send comments or suggestions about this form.

GENERAL INSTRUCTIONS
This form must be completed whenever there is a change in the financial institution information (Part II). The information contained in
this form will supersede any information provided on previously submitted forms.
PART I - EDUCATIONAL INSTITUTION INFORMATION
1. NAME OF EDUCATIONAL INSTITUTION

2. ADDRESS OF INSTITUTION
Number and Street

Unit/Bldg. Number

City, State, Zip
3. FACILITY CODE

PART I I - FINANCIAL INSTITUTION INFORMATION
4. NAME OF FINANCIAL INSTITUTION

5. ADDRESS OF INSTITUTION
Number and Street

Unit/Bldg. Number

City, State, Zip
6. FINANCIAL ACCOUNT INFORMATION
Nine Digit Routing
Transit Number

Type of Account
(Check appropriate box)

Checking

Savings

Depositor Account Number

PART I I I - CONTACT INFORMATION
7. CONTACT PERSON

8. TELEPHONE NUMBER

PENALTY - The law provides that whoever makes any statement of a material fact knowing it to be false shall be punished by fine or imprisonment or both.
SIGNATURE
TITLE
DATE

VA FORM
FEB 2009

22-8794a