Standard Form 1199a (Eg) - Direct Deposit Sign-Up Form Page 2

Download a blank fillable Standard Form 1199a (Eg) - Direct Deposit Sign-Up Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Standard Form 1199a (Eg) - Direct Deposit Sign-Up Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SF 1199A (Back)
BURDEN ESTIMATE STATEMENT
The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property &
Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget,
Paperwork Reduction Project (1510-0007), Washington, D.C. 20503.
PLEASE READ THIS CAREFULLY
All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or
210. The information is confidential and is needed to prove entitlement to payments. The information will be used to
process payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requested
information may affect the processing of this form and may delay or prevent the receipt of payments through the Direct
Deposit/Electronic Funds Transfer Program.
INFORMATION FOUND ON CHECKS
Most of the information needed to complete boxes A,
15-51
United States Treasury
000
C, and F in Section 1 is printed on your government
Check No.
Month Day Year
AUSTIN, TEXAS
check:
0000 415785
08
31
84
A
C
DOLLARS
CTS
Be sure that payee’s name is written exactly as it ap-
29-693-775
00
28
28
pears on the check. Be sure current address is shown.
$
Pay to
VA COMP
****100
00
JOHN DOE
the order of
C
Claim numbers and suffixes are printed here on checks
123 BRISTOL STREET
F
beneath the date for the type of payment shown here.
HAWKINS BRANCH TX 76543
Check the Green Book for the location of prefixes and
suffixes for other types of payments.
A
NOT NEGOTIABLE
F
Type of payment is printed to the left of the amount.
’:00000518’: 041571926"
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
Joint account holders should immediately advise both the Government agency and the financial institution of the death
of a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments, are to be returned to
the Government agency. The Government agency will then make a determination regarding survivor rights, calculate
survivor benefit payments, if any, and begin payments.
CANCELLATION
The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the
Federal agency or by the death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should
notify the receiving financial institution that he/she is doing so.
The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient
a written notice 30 days in advance of the cancellation date. The recipient must immediately advise the Federal agency if
the authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by advice
to the Government agency.
CHANGING RECEIVING FINANCIAL INSTITUTIONS
The payee’s Direct Deposit will continue to be received by the selected financial institution until the Government agency
is notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effect this
change, the payee will complete a new SF 1199A at the newly selected financial institution. It is recommended that the
payee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institution
receives the payee’s Direct Deposit payment.
FALSE STATEMENTS OR FRAUDULENT CLAIMS
Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for
presenting a false statement or making a fraudulent claim.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2