Direct Deposit Sign-Up Form
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of Federal Benefit Payments
FMS Form 1200 (January 2008)
OMB No. 1510'()007
(for social security, railroad retirement board, or civil (non-military)
retirement payments or VA only).
DIRECTIONS
Please read the information on page
2
before completing this form. You must complete boxes
A,
B, C,
D ,
E and
F.
Only complete thisform to sign up for direct deposit if you are an individual, or a representat ive 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.
A.
FEDERAL BENEFIT RECIPIENT INFORMATION
B.
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)
01
NAME OF REPRESENTATIVE PAYEE
YES
(lit
yes. enl er ) NO
nama al "
hi
ADDRESS (street. route.
po.
box. apartment num ber)
CITY
(or
APOIFF'O)
STATE
ZIP CODE
DAYTIME TEl£PHONENUMBER
(
)
-
SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO G<MRNM ENT BENEFITS
(BENEFICIARy)
I
I
I
H
I
H
I
I
I
I
DEPOS ITOR ACCOUNT TITLE (name{s] on account)
ACCOUNT TYPE
Checking
D
Sa ving s
D
•• 9·DlGIT ROUTING NUMBER
(see sample check below)
1
I
I I I I I
I I I
•' ACCOUNT NUMBER (see sample check below;
do
not incfudecheck number)
..
Youmay al soattach avOided personal check. If you are depOSiting Into asa vings account, you
. .... . .,.,:'.. ;....:< ..... '
, " , "
may need to contact your financial instit utionto obtainthe routing and account numbers.
SAM PLE CHECK (bol/om lefl corner) . .
C.
TYPE OF PAYM ENT
(check only one) You must complete a separate form for each type of federal payment.
o
SOCIAL SECURITY OSUPPLEMENTALSECURITYINCOME OVA (COMP/PENSIONONLy)
RAILROAD RETIREMENT
CIVIL (NON·MIUTARy) RETIREMENT
(specify below)
(specify below)
FOI mili tary , federal salary, veterans benefits or other federal payments not available
through
Go
Direct,
pl.... contact th. paying ag.ncy
Annuity
D
Unemployment
D
Retirement
D
Survivor
D
(jee p,ge
2
for, pur/ii/list of paying agoncie.).
benefit
survivor benefit
annuily
annuity
D.
IDENTIFICATION
E.
PAYMENT VERIFICATION
CLAIM NUMBER
You must also enter the amount
In order to process your request, either the daim
of your last payment.
OR
number (found on documents from your paying
agency)
or
the check number from your list payment
, - _
_
_
_
_
_
_1
AMOUNT OF YOUR MOST RECENT PAYMENT
CHECK NUMBER (yOUR MOST RECENT PAYMEN'F)
(found in the upper right-hand corner of your
Treasury check) must be entered at left.
$1
1.[0
I I 1 I I I I I I I: I I I
F.
CERTIFICATION
I certify that I am entitled to receive the payfrent identified above, and that I
have read and understand the back of this fb,rm. In signing this form, I
authorize this payment to be sent to the financial institution named in Part
B
above, to be deposited into the account above.
SIGNATURE
I
DATE
FOR JOINT ACCOUNT HOLDERS
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS on the back of this form.
SIGNATURE
I
DATE
I
Be sure to complete ali sections of this form.
Otherwise, the form cannot be
Return the completed form to:
Go Direct Processing Center
I
U.S. Department of the Treasury
P.O. Box 650527
I '
Dallas, TX
Tiiis form is-only to be lised for switchingfrom aheck payments to direct deposit of cerrain f ederal
benefits listed in Box C. Use'Ofthisform for any ot,her purposes will result in the formbeingr.ejected.
Contact your paying agency to:
- UPda,te your ngme or address .
-Change your \ICcounl information
If
you already r!3CeiveJyour payment by direct deposit; or
• Sign up
for
direct deposit for military, federal salary, veterims benefits, or
other
federal payment s
not processed by GoDirect.
_.. ._ ' -. ._ .._.c:...
Direct Deposit Sign-Up
FMS Form 1200 (January 2008)
Bankers Systems
TM
1200 1/ 1/2009
Wolters KJuwer Fin31cial Services
Page
1
of
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