Fillable Direct Deposit Sign Up Form - Gte Financial printable pdf download

Sign-Up Form for

Direct Deposit

You may also sign up online today at

or call

Go Direct

toll free at 1 (800) 333-1795

of Federal Benefit Payments

(for social security, railroad retirement board, civil (non-military)

retirement payments or VA

only

FMS Form 1200

OMB No. 1510-0007

(January 2008)

DIRECTIONS

You must complete boxes A, B, C, D, E and F.

Please read the information on page 2 before completing this form.

Only complete this form to sign up for direct deposit if you are an individual, or a representative payee of an individual, who receives checks

for the following types of federal benefits: social security, supplemental security income, railroad retirement, civil (non-military)

retirement, or VA (compensation or pension only). If you currently receive your payment by direct deposit you may not use

this form. Please refer to page 2 for further instructions.

FEDERAL BENEFIT RECIPIENT INFORMATION

BANK OR CREDIT UNION INFORMATION

(print name[s] and address exactly as they appear on your benefit check)

NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)

DEPOSITOR ACCOUNT TITLE (name[s] on account)

REPRESENTATIVE PAYEE?

NAME OF REPRESENTATIVE PAYEE

** 9-DIGIT ROUTING NUMBER

ACCOUNT TYPE

Yes

if yes, enter

name at right

(see sample check below)

Checking

Savings

ADDRESS (street, route, P.O. box, apartment number)

2 6 3 1 8 2 7 9 4

CITY

(or APO/FPO)

STATE

ZIP CODE

** ACCOUNT NUMBER (see sample check below; do not include check number)

DAYTIME TELEPHONE NUMBER

** You may also attach a voided personal check. If you are depositing into a savings account, you

(

) ___________ - _______________

may need to contact your financial institution to obtain the routing and account numbers.

SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS

(BENEFICIARY)

111999087

9876554321

0001

SAMPLE CHECK (bottom left corner)

ROUTING NUMBER

ACCOUNT NUMBER

CHECK NUMBER

TYPE OF PAYMENT

(check only one) You must complete a separate form for each type of federal payment.

SOCIAL SECURITY

SUPPLEMENTAL SECURITY INCOME

VA (COMP/PENSION ONLY)

RAILROAD RETIREMENT

CIVIL (NON-MILITARY) RETIREMENT

(specify below)

For military, federal salary, veterans benefits or other federal payments

Survivor

Annuity

Unemployment

Retirement

not available through Go Direct, please contact the paying agency

annuity

benefit

survivor benefit

annuity

(see page 2 for a partial list of paying agencies).

IDENTIFICATION

PAYMENT VERIFICATION

CLAIM NUMBER

In order to process your request,

either

the claim

You must

also

enter the amount

number (found on documents from your paying

of your last benefit payment.

agency)

the check number from your last

CHECK NUMBER (YOUR MOST RECENT PAYMENT)

AMOUNT OF YOUR MOST RECENT PAYMENT

payment (found in the upper right-hand corner

of your Treasury check)

must be entered

at left.

CERTIFICATION

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

FOR JOINT ACCOUNT HOLDERS

read and understand the back of this form. In signing this form, I authorize this

payment to be sent to the financial institution named in Part B above, to be

I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT

deposited into the account above.

HOLDERS on the back of this form.

SIGNATURE

DATE

SIGNATURE

DATE

Be sure to complete all sections of this form.

This form is

only

to be used for switching from check payments to direct deposit of certain federal

Otherwise, the form cannot be processed.

benefits listed in Box C. Use of this form for any other purposes will result in the form being rejected.

Return the completed form to:

Contact your paying agency to:

Go Direct Processing Center

Update your name or address

U.S. Department of the Treasury

Change your account information if you already receive your payment by direct deposit, or

P.O Box 650527

payments not processed by

Go Direct

Dallas, TX 75265-0527

Direct Deposit Sign Up Form - Gte Financial

Related Articles

Related forms

Related Categories