The Direct Express® Debit MasterCard® is issued by Comerica Bank, Bank pursuant to a license by MasterCard International nternational Incorporated. MasterCard® and MasterCard® Brand Mark are registered trade marks of MasterCard International Incorporated. A Great news for those receiving VA Compensation or Pensi on, RRB Annui ty and OPM (Federal Retirement) benefits! One quick call to us at 1-800-333-1795 is all you need to do to begin to receive your payments on the Direct Express® card. No paper form is required! Calls us today to enroll. Direct Express® Express and the Dir ect Express® logo are service marks of the U.S. Department of the Treasury, Financial Management Services (used with permission). How to Apply for the Direct Express® Card You are receiving this Application for the Direct Express® Debit MasterCard® Card because: • You asked us to send you information, and/or • We were unable to process your Application when you tried to sign up for the Direct Express® Card.. Please complete the enclosed Application so that we may confirm your personal information. HOW DO I COMPLETE THE APPLICATION? If you are a Benefit Recipient (a person who is entitled to F Federal benefits): • Complete Sections 1 and 4 on the enclosed Application • Mail the completed and signed Application, along with the documents described in Section 3 of the Application, to the address below. If you are a Representative Payee (a person who receives payments for one or more Benefit Recipients): • Complete Sections 1, 2, and 4 on the enclosed Application. If you are the Representative Payee for more than one Benefit Recipient, please complete a separate Application for each recipient. • Mail the completed and signed Application, along with the documents described in Section 3 of the Application, to the address below. Mail your completed and signed application, along with copies of the required documents, to: Direct Express® PO Box 7050 London, KY 40742 What Happens Next? Once we receive your documents, your Application for the Direct Express® debit card will be processed. If we are able to verify your personal information and the federal agency confirms your payment information, you should receive your Direct Express® debit card in 7 to 14 days. Your payments will then be automatically deposited to your new debit card account on the same day you currently receive your regular paper check. You may receive one more paper check before yo your ur payments are switched to your new Direct Express® debit card. If your information is not complete or we still are not able to verify your personal information or benefit eligibility, a Direct Express® Customer Service Representative will contact you. D ire ct Express® Express and t he D ir ect Expre ss® logo are service marks of the U.S . De partment of the Treasury, Financial Manage me nt Se rvices (used with permission). APPLICATION FOR DIRECT EXPRESS® DEBIT MASTERCARD® CARD Section 1. Benefit Recipient Information (about the person who is entitled to Federal benefits) Payment Type: SSA Benefits SSI Benefits Name: ________________________________________________ Date of Birth: ________/________/_________ Social Security Number: _______-_____ ___-__________ __________ Daytime Phone: ( ) __________________________ Current Mailing Address: _______________________________________________________________________ City: ___________________________________ State: ___________________ Zip Code: ___________________ Section 2. Representative Payee Information (about the person who receives payments for one or more Benefit Recipients) If you are a Representative Payee for more than one Benefit Recipient, please submit a separate Application for each Benefit Recipient. Name: ________________________________________________ Date of Birth: ________/________/_________ ________/___ Social Security Number: _______-_______ ___-__________ __________ Daytime Phone: ( ) __________________________ Current Mailing Address: _______________________________________________________________________ City: _______________________________ ___________________________________ ____ State: ___________________ Zip Code: ___________________ Section 3. Verification of Personal Information Information. To verify your personal information, please enclose copies (no originals, please) of each of the following: Valid,, government issued, photo identification. For example: driver’s license, state issued photo identity card, or passport. A Representative epresentative Payee ayee should submit their own identification, not the beneficiary’s identification. If your address ress has recently changed, please send us identification with the correct address; and Recent Social Security benefit check (Do not send original check) or your last SSA-1099. SSA The check should not be more than 31 days old; the SSA SSA-1099 should not be more re than 1 year old, and Utility bill that is less than 60 days old and is addressed to you at your current address. For example: electric bill, gas bill, phone bill, water bill, or cable bill. A Representative Payee should submit their own utility bill, not the beneficiary’s bill. Section 4.. Authorization and Affirmation: ® I authorize the Federal Agency that pays my benefits to credit all of my payments to my Direct Express debit card ® account. I understand that the Direct Express card will be mailed to me once my personal information and eligibility to receive benefits have been confirmed. To the best of my knowledge, the information contained in this Application is true, accurate, and complete. __________________________ Date:: _________________________ Signature: ________________________________________________ Mail your completed and signed application, along with copies of the required documents, to: Direct Express® PO Box 7050 London, KY 40742 The Direct Express® Debit MasterCard® is issued by Comerica Bank, pursuant to a license by MasterCard International Incorporated. MasterCard® and MasterCard® Brand Mark are registered trade marks of MasterCard International Incorporated.