OMB Approved No. 2900-0564
Please read the Privacy Act and Respondent Burden information shown below.
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ATTENTION VA BENEFICIARY! |
Privacy Act Notice: VA will not disclose information collected on this form to any source |
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WE'VE MADE ENROLLING IN DIRECT DEPOSIT EASIER THAN EVER! |
other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of |
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Federal Regulations 1.576 for routine uses as identified in the VA system of records, |
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CALL TOLL FREE - 1-800-827-1000 |
58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and |
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or TDD 1-800-829-4833 (Telephone Device for the Hearing Impaired) |
Employment Records - VA, published in the Federal Register. Your obligation to respond |
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is voluntary. The information solicited under authority of Title 31 Code of Federal |
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Direct Deposit is the safest, fastest and most cost efficient method to receive your payment. In |
Regulations, Section 210.4 will be used to process the payment data from VA to your |
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account at the designated financial institution. Giving us your Social Security Number |
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addition, you no longer have to worry about your check being late, lost, or stolen. NOTE: The |
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(SSN) is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. |
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"Debt Collection Improvement Act of 1996" which was signed into law on April 26, 1996 required |
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all Federal payments to be made by Electronic Fund Transfer (EFT or Direct Deposit) beginning |
5101 (c) (1). VA will not deny an individual benefits for refusing to provide his or her |
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January 1, 1999. Waivers will be available where the conversion from paper checks imposes a |
SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior |
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to January 1, 1975, and still in effect. The requested information is considered relevant |
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hardship. Write to the address shown below for more information concerning a waiver. To have |
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and necessary to determine maximum benefits provided by law. The responses you submit |
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your VA compensation, pension, education, or spina bifida payment deposited into your account |
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right away with Direct Deposit just call VA's toll-free number above or complete this form and |
are considered confidential (38 U.S.C. 5701). |
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mail to: |
Department of Veterans Affairs |
Respondent Burden: We need this information to ensure proper transmission of your |
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funds via electronic transfer to your financial institution (31 CFR 208.3 and 210.4). Title |
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125 S. Main Street Suite B |
38, United States Code, allows us to ask for this information. We estimate that you will |
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Muskogee OK 74401-7004 |
need an average of 15 minutes to review the instructions, find the information, and |
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complete this form. VA cannot conduct or sponsor a collection of information unless a |
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When you call, be sure to have a personal check or bank statement available as well as your VA Claim |
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valid OMB control number is displayed. You are not required to respond to a collection of |
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Number or Social Security Number. The VA representative will ask for information from these |
information if this number is not displayed. Valid OMB control numbers can be located |
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documents to start your Direct Deposit. If you prefer to enroll by mail, just complete the information |
on the OMB Internet Page at |
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below, and attach a voided personal check from your checking account or call your Financial Institution |
www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get |
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and verify the information requested below for a savings account. |
information on where to send comments or suggestions about this form. |