Standard Form 1199A
OMB No. 1510-0007
(Rev. June 1987)
Prescribed by Treasury
Treasury Dept. Cir. 1076
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)
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS’ CERTIFICATION
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.