Electronic Transfer Account Request for Information data form

PRIVACY STATEMENT

Request For ETA Information: This information will only be used to fulfill your information request and offer you the opportunity to open an ETA and/or sign up for Direct Deposit.
required fields are denoted with an *.

Please provide the following information:

Name:
Title:*
First:
Middle:
Last: *

Mailing Address: ZIP Code will supply City and State.
Street 1: *
Street 2:
Apt/Unit:
ZIP: *

Would you like this information in:

How did you hear about the ETA? *

Providing the following information is optional, but will assist us in fulfilling your request.

Do you currently have any type of bank account (Savings/Checking)?

Type of Federal payment you receive (Please select all that apply):

	Social Security
	Supplemental Security Income
	Railroad Retirement Board Benefits
	Civil Service Retirement (OPM)

	VA Compensation or Pension
	VA Education Benefit
	DOL/Black Lung
	Civilian or Military Salary or Wage

Comments:

This information will be transmitted via a Secure Socket Layer (SSL).

For more information regarding the ETA, you may also call: 1 (888) 382-3311 or 1 (877) 326-5833 (TTD)

Government Agencies | Financial Institution | Social Agencies