Travel Mileage Reimbursement Change (Page 4 of 4) in pdf

Travel Mileage Reimbursement Change Page 4

Department of Veterans Affairs

VA Roseburg Healthcare System

Direct Deposit Enrollment Form

Dear Veteran,

The U.S. Department of Treasury, under 31 CFR Part 208, now requires Federal payments,

including beneficiary travel and compensated work therapy, to be made electronically. The

information you provide on this from will be used by the Treasury to transmit payment data

though electronic funds transfer to your financial institution.

Complete all fields in the Information Section below. To return your form, you may:

You must attach a voided check to this request form.

•

Bring the completed form to the VA Roseburg Healthcare System campus’ Agent

•

Cashier Office (Building 1, Room D108) now or at your next appointment.

Fax it to our secure fax line at (541) 677-3043; or

•

Mail to ATTN: AGENT CASHIER/ 913 NW Garden Valley Blvd / Roseburg / OR / 97471

•

First & Last Name

Social Security#

Address ____________________________________ City________________State____Zip_________

Bank Name

City

State

Zip

Routing Transit #

Account #_________________________________

(Routing Transit # Found on the bottom of your personal check, must have 9 digits and begin with “0”, “1”, “2” or “3”)

Circle Account Type:

Checking

Savings

Signature

Phone # (

) __________

____________

_____

For questions concerning the EFT process, please contact the Fiscal Office at

(541) 440-1000 ext. 44265/44790/45568/44269.

Date: 05/28/2013

Travel Mileage Reimbursement Change Page 4