Standard Form 1199a - Direct Deposit Sign-Up Form printable pdf download

S ta n da rd F o r m 119 9A ( E ) , C D C Ad ob e A cr oba t 5. 0 E l ect ron i c V er s i on, 8/ 200 1

OMB No. 1510-0007

(Rev. June 1987)

1-31-93

Expiration Date

Prescribed by Treasury

Department

SIGN-UP FORM

DIRECT

DEPOSIT

Treasury Dept. Cir. 1076

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DIRECTIONS

To sign up for Direct Deposit, the payee is to read the back of this

The claim number and type of payment are printed on Government

form and fill in the information requested in Sections 1 and 2. Then

checks. (See the sample check on the back of this form.) This informa-

take or mail this form to the financial institution. The financial in-

tion is also stated on beneficiary/annuitant award letters and other

stitution will verify the information in Sections I and 2, and will com-

documents from the Government agency.

plete Section 3. The completed form will be returned to the Govern-

ment agency identified below.

Payees must keep the Government agency informed of any address

changes in order to receive important information about benefits and

A separate form must be completed for each type of payment to be

to remain qualified for payments.

sent by Direct Deposit.

SECTION 1 (TO BE COMPLETED BY PAYEE)

NAME OF PAYEE

(last, first, middle initial)

TYPE OF DEPOSITOR ACCOUNT

CHECKING

SAVINGS

DEPOSITOR ACCOUNT NUMBER

(street, route, P.O. Box, APO/FPO)

ADDRESS

CITY

STATE

ZIP CODE

(Check only one)

TYPE OF PAYMENT

Fed Salary/Mil. Civilian Pay

Social Security

Mil. Active

Supplemental Security Income

TELEPHONE NUMBER

Mil. Retire

Railroad Retirement

AREA CODE

Civil Service Retirement (OPM)

Mil. Survivor

NAME OF PERSON(S) ENTITLED TO PAYMENT

VA Compensation or Pension

Other

(specify)

(if applicable)

CLAIM OR PAYROLL ID NUMBER

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY

TYPE

AMOUNT

Prefix

Suffix

PAYEE/JOINT PAYEE CERTIFICATION

JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)

I certify that I have read and understood the back of this form, including

I certify that I am entitled to the payment identified above, and that I

have read and understood the back of this form. In signing this form, I

the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

authorize my payment to be sent to the financial institution named

below to be deposited to the designated account.

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)

GOVERNMENT AGENCY NAME

GOVERNMENT AGENCY ADDRESS

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

CHECK

NAME AND ADDRESS OF FINANCIAL INSTITUTION

ROUTING NUMBER

DIGIT

DEPOSITOR ACCOUNT TITLE

FINANCIAL INSTITUTION CERTIFICATION

I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, I cer-

tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and 210.

PRINT OR TYPE REPRESENTATIVE'S NAME

TELEPHONE NUMBER

DATE

SIGNATURE OF REPRESENTATIVE

Financial institutions should refer to the GREEN BOOK for further instructions.

THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.

GOVERNMENT AGENCY COPY

NSN 7540-01-058-0224

1199-206

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Standard Form 1199a - Direct Deposit Sign-Up Form

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