Social Security Direct Deposit Sign Up Form
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1
2OMB No. 1510-0007
Go Direct
SM
Or call
at 1 (800) 333-1795
TEST Standard Form 1199A
to sign up today.*
(August 2005)
Prescribed by Treasury Department
Treasury Department Cir. 1076
DIRECTIONS
Please refer to the information on the reverse side before completing this form. You must complete a separate form for each type of federal
payment (social security, supplemental security income, veterans’ benefits, etc.).
You are responsible for keeping the paying agency informed of any name or address changes. Return the completed form to the federal
agency from which you will be receiving Direct Deposit payments. Check the Government Listings Section of your local telephone directory for
the nearest office.
Go Direct
* If you elect to enroll by phone, the
toll-free number may only be used for social security, railroad retirement or Office of Personnel
Management payments. You may also contact each agency individually at the toll-free number below. For veterans benefits and all other types
of federal payments, you must enroll directly through your paying agency either by phone or completing and mailing this form.
*
Railroad Retirement Board
Department of Veterans Affairs
(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
(888) 767-6738
(800) 772-1213
(800) 325-0778 TTY
(800) 878-5707 TDD
A.
C.
FEDERAL BENEFIT RECIPIENT INFORMATION
BANK OR CREDIT UNION INFORMATION
NAME OF FEDERAL BENEFIT RECIPIENT
DEPOSITOR ACCOUNT TITLE (name[s] on account)
REPRESENTATIVE PAYEE?
NAME OF LEGAL REPRESENTATIVE
** 9-DIGIT ROUTING NUMBER
ACCOUNT TYPE
Yes
if yes, enter
No
(see sample check on reverse side)
name at right
Checking
Savings
ADDRESS (street, route, P.O. box, apartment number)
CITY
(or APO/FPO)
STATE
ZIP CODE
** ACCOUNT NUMBER (see sample check on reverse side)
TELEPHONE NUMBER
** You may also attach a voided personal check.
(
) ___________ - _______________
SOCIAL SECURITY OR CLAIM NUMBER
(under which the current federal benefit payment is received)
D.
CERTIFICATION
I certify that I am entitled to receive the payment identified above, and that I have
B.
read and understand the back of this form. In signing this form, I authorize this
TYPE OF PAYMENT
(check only one)
payment to be sent to the financial institution named in Part C above, to be
MILITARY (
specify below
)
deposited into the account above.
SOCIAL SECURITY
Active
Retired
Survivor
SIGNATURE
DATE
SUPPLEMENTAL SECURITY INCOME
FEDERAL SALARY
RAILROAD RETIREMENT
(specify below)
VA COMPENSATION OR PENSION
Annuity
Unemployment
benefit
survivor benefit
OTHER (
specify
) ________________
FOR JOINT ACCOUNT HOLDERS
CIVIL SERVICE (OPM) RETIREMENT
(specify below)
(Military, Federal Salary, VA and
Retirement
Survivor
Go Direct
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
“Other” not available through
)
annuity
annuity
HOLDERS on the back of this form.
ALLOTMENT (
if applicable
)
(
type
)___________________________________
SIGNATURE
DATE
(a
mount
)________________________________
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