Bank Account Details for Overseas Residents - Department of ...

D9197.3/10 (Page 1 of 2)Bank Account Detailsfor Overseas ResidentsWire Payment via a USA bankYou should use this form if you are living outside Australia and you want your Departmentof Veterans' Affairs (DVA) payments made into an account with a bank or financialinstitution in the country in which you are living.Your payments will be issued electronically in your local currency to the account younominate.Please note that payments may be subject to fees levied by your bank, and such feesmust be paid by you.Please confirm with your bank or financial institution that your account is capableof receiving wire payments in US Dollars. The nominated account must be in yourname, or that of your appointed DVA agent or trustee, or it may be a joint account withanother person. If you would like to appoint an agent or trustee to act on your behalfin dealings with DVA, please contact us.Please fill in the details overleaf in BLOCK letters, and then ask your bank or financialinstitution to verify the information you have supplied.Please attach a copy of a bank document that shows your bank details, including youraccount number, the name(s) of the account holder(s) and, if possible, your InternationalBank Account Number (IBAN). Once the form is completed and your bank has confirmedthe details, please sign the form and return it to the address below. Make sure youapply sufficient postage stamps to ensure the form is sent by airmail, otherwise delaysmay occur.If you need help, contact DVA Income Support, Tasmania (contact details below).Postal addressIncome SupportDepartment of Veterans’ AffairsGPO Box 9998Hobart TAS 7001AUSTRALIAEmail address GeneralEnquiries@dva.gov.auFax number +61 3 6221 6660Telephone number +61 3 6221 6782

D9197.3/10 (Page 2 of 2)Bank Account Detailsfor Overseas ResidentsWire Payment via a USA bankPlease fill in the details below in BLOCK letters, and then ask your bank or financial institution to verify the information you have supplied.Name of Bank or FinancialInstitutionAddress of Bank or FinancialInstitution BranchNumber/StreetTown/City/PostcodeCountrySWIFT Bank Identifier Code (BIC)Account NumberInternational Bank Account Number(IBAN)Name of Account HolderName of intermediary Bank in USAAddress of intermediary Bank inUSAPlease ask your bank or financial institution to complete the details belowNumber/StreetTown/City/PostcodeSWIFT Bank Identifier Code (BIC)Bank Sort Code/Routing code ofintermediary Bank in USATo the Bank/Financial InstitutionBank/Financial Institution StampNote: This is NOT the Bank Identifier Code (BIC).We confirm that the customer account can receive deposits by electronic means via theintermediary bank in the USA whose details are provided by us above.We verify that the account details of the customer are correct.Your statementYour signatureI have attached a copy of a bank document that shows my bank details, including myaccount number and the name(s) of the account holder(s).✍DateYour name (please print)DVA or DEFCARE File No. (if known)Your Contact Details (optional)Home phone numberEmail