VA Form 24-0296a International Direct Deposit Enrollment

OMB Approved No. 2900-0564
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

INTERNATIONAL DIRECT DEPOSIT ENROLLMENT
IMPORTANT: Please complete all requested information in order to successfully enroll in International Direct Deposit.
Please print clearly. Be sure to sign and date.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER

Month

Day

Year

SECTION II: BENEFICIARY'S IDENTIFICATION INFORMATION
5. BENEFICIARY'S NAME (First, Middle Initial, Last - If other than veteran)

6. ADDRESS OF PERSON RECEIVING PAYMENT (Check box if new

)

8. TELEPHONE NUMBER (Include Area Code)

7. VA FILE NUMBER

9. E-MAIL ADDRESS (Write "None," if you don't have

one)

SECTION III: BANK INFORMATION
10. NAME OF BANK

11. ADDRESS OF BANK

12. COUNTRY

13. BANK CODE

14. BRANCH CODE

15. ACCOUNT NUMBER

16. SWIFT CODE (Required for Euro payments)

17. IBAN NUMBER (Required for Euro payments)

19. THIS ACCOUNT IS:

18. 18 DIGIT CLABE NUMBER (Required for payments to Mexican Banks)

MY OWN ACCOUNT

CHECKING

U.S. DOLLARS

A JOINT ACCOUNT

SAVINGS

LOCAL CURRENCY

SECTION IV: PAYEE CERTIFICATION
I CERTIFY THAT I am entitled to the payment identified above, and that I have read and understand this form. In signing this form, In signing this form, I authorize this
payment to be sent to the financial institution named in Section III above, to be deposited into the account above.
16. DATE SIGNED

15. SIGNATURE OF PAYEE (Do NOT print - Sign in ink)

PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside
VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.
Information submitted is subject to verification through computer matching programs with other agencies. VA may make a “routine use” disclosure for: civil or criminal law enforcement,
congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the
administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration. Your obligation to respond is required in order to obtain or retain
benefits (31 CFR 208.3 and 210.4). Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of determining your eligibility to
receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs. Social
Security information: You are required to provide the Social Security number requested under 38 U.S.C. 5101( c) (1) . VA may disclose Social Security numbers as authorized under the Privacy Act,
and, specifically may disclose them for purposes stated above.
Respondent Burden: We need this information to ensure proper transmission of your funds via electronic transfer to your financial institution (31 CFR 208.3 and 210.4). Title 38, United States Code,
allows us to ask for this information. 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this
form.

MAIL TO: Department of Veterans Affairs
125 S Main Street
Muskogee, OK 74401
E-Mail: [email protected]
Or Fax: (918) 781-7573
VA FORM
XXXX

24-0296A

SUPERSEDES VA FORM 24-0296, MAR 2018,
WHICH WILL NOT BE USED.