Form 1199a - Direct Deposit Sign-Up Form Page 3
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1
2
3FOR SALE BY THE SUPERINTENDENT OF DOCUMENTS. US GOVERNMENT PRINTING OFFICE
WASHINGTON, DC 20402 STOCK NO. 048-000-00363-0
OMB No. 1510-0007
Standard Form 1199A
Expiration Date 1-31-93
(Rev. June 1987)
Prescribed by Treasury
SIGN-UP FORM
DIRECT
DEPOSIT
Department
Treasury Dept. Cir. 1076
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 Section 1 and 2. Then
checks.
(See the sample check on the back of this form.)
This
take or mail this form to the financial institution.
The financial
information is also stated on beneficiary/annuitant award letters and
institution will verify the information in Sections 1 and 2, and will
other documents from the Government agency.
complete Section 3.
The completed form will be returned to the
•
Government 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)
A
D
TYPE OF DEPOSIT OR ACCOUNT
CHECKING
SAVINGS
E
DEPOSIT OR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
F
CITY
STATE
ZIP Code
TYPE OF PAYMENT (Check only one)
Social Security
Fed Salary/Mil. Civilian Pay
TELEPHONE NUMBER
Supplemental Security Income
Mil. Active
AREA CODE
Railroad Retirement
Mil. Retire.
Civil Service Retirement (OPM)
Mil. Survivor
NAME OF PERSON(S) ENTITLED TO PAYMENT
B
VA Compensation or Pension
Other
(specify)
CLAIM OR PAYROLL ID NUMBER
G
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
C
TYPE
AMOUNT
Prefix
Suffix
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
I certify that I am entitled to the payment identified above, and that I have
I certify that I have read and understood the back of this form, including the
read and understood the back of this form. In signing this form, I authorize
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
my payment to be sent to the financial institution named below to be
deposited to the designated account.
SIGNATURE
DATED
SIGNATURE
DATE
SIGNATURE
DATED
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)
NAME AND ADDRESS OF FINANCIAL INSTITUTION
ROUTING NUMBER
CHECK
DIGIT
DEPOSIT OR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-name payee(s) and the account number and title. As representative of the above-named financial institution, I certify 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
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
DATE
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.
PAYEE(S) COPY
1199-206
NSN 7540-01-058-0224
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