Standard Form 1199a (Eg) - Direct Deposit Sign-Up Form
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1
2Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. June 1987)
Prescribed by Treasury
DIRECT DEPOSIT SIGN-UP FORM
Department
Treasury Dept. Cir. 1076
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
and fill in the information requested in Sections 1 and 2. Then take or
checks.
(See the sample check on the back of this form.)
This
mail this form to the financial institution. The financial institution will
information is also stated on beneficiary/annuitant award letters and
verify the information in Sections 1 and 2, and will complete Section 3.
other documents from the Government agency.
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 to
A separate form must be completed for each type of payment to be
remain qualified for payments.
sent by Direct Deposit.
SECTION 1 (TO BE COMPLETED BY PAYEE)
A
NAME OF PAYEE (last, first, middle initial)
D
TYPE OF DEPOSITOR ACCOUNT
CHECKING
SAVINGS
E
DEPOSITOR 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
Supplemental Security Income
Mil. Active
TELEPHONE NUMBER
Railroad Retirement
Mil. Retire.
AREA CODE
Civil Service Retirement (OPM)
Mil. Survivor
B
NAME OF PERSON(S) ENTITLED TO PAYMENT
VA Compensation or Pension
Other
pecify)
(s
C
G
CLAIM OR PAYROLL ID NUMBER
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
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,
read and understood the back of this form. In signing this form, I
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
authorize my payment to be sent to the financial institution named below
to be deposited to the designated account.
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
DATE
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
CHECK
ROUTING NUMBER
DIGIT
SOUTH BAY CREDIT UNION
3
2
2
2
8
1
0
2
8
312 N. PACIFIC COAST HWY.
REDONDO BEACH, CA 90277
DEPOSITOR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named 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.
Reset
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
PAYEE COPY
NSN 7540-01-058-0224
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
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