Standard Form 1199a - Sign-Up For Direct Deposit Form

Download a blank fillable Standard Form 1199a - Sign-Up For Direct Deposit 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 - Sign-Up For Direct Deposit 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.

Standard Form 1199A

OMB No. 1510-0007

(Rev. June 1987)

SIGN-UP FORM

Prescribed by Treasury

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 Sections 1 and 2. Then

checks. (See the sample check on the back of this form.) This informa-

take or mail this form to the financial institution. The financial in-

tion is also stated on beneficiary/annuitant award letters and other

stitution will verify the information in Sections 1 and 2, and will com-

documents from the Government agency.

plete Section 3. The completed form will be returned to the Govern-

ment 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)

(last, first, middle initial)

(street, route, P.O. Box, APO/FPO)

(Check only one)

(specify)

(if applicable)

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

I certify that I have read and understood the back of this form, including

have read and understood the back of this form. In signing this form I

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.

SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

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 cer-

tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and 210.

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.

1199-207

NSN 7540-01-058-0224