VA Form 29-0165 VA MATIC Enrollment/Change

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

29-0165(11-9-22)

OMB: 2900-0525

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OMB Approved No. 2900-0525
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

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 (Sign in ink)

6. DATE

SECTION II - PREMIUM PAYMENT INFORMATION
8. PHONE NUMBER OF BANK/FINANCIAL INSTITUTION

7. NAME 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 :

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

1617284958569678

Bank Routing
Number

Bank Account
Number

11. DO YOU PARTICIPATE IN DIRECT DEPOSIT? IF YES, WILL THIS NEW INFORMATION APPLY TO DIRECT DEPOSIT?
YES

NO

NOTE: PLEASE PROVIDE A COPY OF THE POWER OF ATTORNEY, IF YOU HAVE NOT ALREADY DONE SO. SENDING A VOIDED CHECK
CAN HELP MAKE SURE YOUR INFORMATION IS PROVIDED CLEARLY, AND COULD PREVENT DELAYS IN PROCESSING.

THIS COMPLETED FORM MAY BE SUBMITTED BY:

ONLINE

OR MAIL THE COMPLETED FORM TO:

Upload the form using our
secure website at
https://insurance.va.gov/home/IDU

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, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance - VA,
published in the Federal Register. Your response is voluntary. VA uses your Social Security Number (SSN) to identify your insurance file. Providing your SSN will help insure that your
records are properly associated with your insurance file. Giving us your SSN 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.
RESPONDENT BURDEN: No insurance deduction may be made unless a completed authorization is received (38 USC 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.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.

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

29-0165

SUPERSEDES VA FORM 29-0165, DEC 2019,
WHICH WILL NOT BE USED.


File Typeapplication/pdf
File TitleVA Form 29-0165
SubjectV. A. Matic Enrollment / Change
AuthorN. KESSINGER
File Modified2022-11-09
File Created2022-11-09

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