Standard Form 1199a - Direct Deposit Sign-Up Form - 1987 Page 2
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1
2CHECKING
SAVINGS
A
D
NAME OF PAYEE (last, first, middle initial)
TYPE OF DEPOSITOR ACCOUNT
E
DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
3 8 5 0 0 0 0
CITY
STATE
ZIP CODE
F
TYPE OF PAYMENT (check only one)
Social Security
Fed Salary/Mil. Civilian Pay
Supplemental Security Income
Mil. Active
TELEPHONE NUMBER
AREA CODE
Railroad Retirement
Mil. Retire
Civil Service Retirement (OPM)
Mil. Survivor
B
NAME OF PERSON(S) ENTITLED TO PAYMENT
VA Compensation or Pension
Other:_____________________
(specfy)
C
G
CLAIM OR PAYROLL ID NUMBER
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
AMOUNT
N/A
Prefix
Suffix
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS` CERTIFICATION (optional)
I certificate that I am entilled to the payment identified above, and that I
I certify that I have read and understood the back of this form, including the
have read and understood the back of this form. In signing this form I
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
N/A
N/A
SIGNATURE
DATE
SIGNATURE
DATE
N/A
N/A
N/A
N/A
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
Zagrebacka Banka
0
2
1
0
0
0
0
1
8
THROUGH BNY Mellon
BNY Mellon, Suite 154-1260, Mellon Client Service Center,
DEPOSIT ACCOUNT TITLE
500 Ross Street, Pittsburgh, PA 15262-0001
ATTN
. ACH DEPARTMENT
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identify of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, Icertify 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 NAME
SIGNATURE OR 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.
NSN 7540-01-058-0224
1199-207
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