Direct Deposit Sign-Up Form Page 2

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PLEASE READ THIS CAREFULLY
PRIVACY ACT NOTICE
Your social security number and the other information requested will allow the federal government to make payments to you by direct
deposit. This collection of information is authorized by Title 31 of the United States Code, Section 3332(g). Also, Executive Order 9397,
November 22, 1943, authorizes the use of your social security number. Your social security number is requested to ensure the accurate
identification and retention of records pertaining to you and to distinguish you from other recipients of federal payments.
This information will be disclosed to the Department of the Treasury or another disbursing official to process federal payments to you by
direct deposit. This information may also be disclosed to acourt, congressional committee or another government agency as authorized or
required by federal law and to your financial institution to verify receipt of your federal payments. Although providing the requested
information is voluntary, your direct deposit payment may be delayed or Treasury may be unable to send it if you fail to provide the
information.
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
If your account is ajOint account and receives direct deposit benefit payments, you must inform the federal agency and the financial
institution of the death of abeneficiary. Payments sent by direct deposit after the date of death or ineligibility of abeneficiary (except for
salary payments) must be returned to the federal agency. The federal agency will then determine if the survivor is eligible for benefits.
CANCELLATION
Your payment will be sent by direct deposit until the federal agency that issues the payments is notified to cancel, such as in the case of
death or legal incapacity of the person receiving the payment.
Your financial institution may cancel your direct deposit authorization. Your financial institution is required to give you written notice 30 days
in advance of the cancellation date. If this occurs, you must notify the federal agency that the direct deposit authorization was cancelled.
Please contact your paying agency to:
• Update your name or address
• Change your account information if you
receive your payment by direct deposit, or
• Sign up for direct deposit for military, federal salary, veterans benefits, or other federal
payments not processed by
Go
Direct
Department of Veterans Affairs
Railroad Retirement Board
(877) 838-2778
(Automated System)
(800) 827-1000
(800) 808-0772
(800) 829-4833 TDD
(312) 751-4701 TTY
Social Security Administration
Office of Personnel Management
(800) 772-1213
(800) 767-6738
(800) 325-0778 TTY
(800) 878-5707 TOO
BURDEN ESTIMATE STATEMENT
The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the
burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information
Management Program, 3700 East-West Highway , Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED FOR
COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OFTIME SPENT COLLECTING THE DATA. DO NOT SEND THE
COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.
Direct
Sign-Up
FMS Form 1200 (January 2008)
Bankers
stemsTM
1200 1/112009
Wolters
uwer Rnancral Services
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