Fillable Direct Deposit Sign-Up Form (Page 4 of 4) in pdf

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, Records Management Branch, Room 135, 3700 East-West Highway, Hyattsville, MD 20782.

THIS ADDRESS SHOULD ONLY BE USED FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT TO

COLLECT THIS DATA. DO NOT SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.

PRIVACY ACT NOTICE

Collection of the information in this Direct Deposit Sign-Up form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397

(November 22, 1943). Your social security number and the other information requested will allow the federal government to process your direct

deposit. Your social security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you

from other recipients of federal payments. This information will be disclosed to the Department of the Treasury and its fiscal and financial agents, and

other federal agencies, as necessary to process your direct deposit. This information may also be disclosed to a court, congressional committee or

another government agency as authorized or required to verify your receipt of federal payments. Although providing the requested information is

voluntary, your direct deposit cannot be processed without it.

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 and F in

15-51

United States Treasury

Section 1 is printed on your government check:

000

Check No.

Month Day Year

KANSAS CITY, MO

0000 415785

DOLLARS

CTS

Be sure that payee’s name is written exactly as it

appears on the check. Be sure current address is shown.

Pay to

VA COMP

****100

JOHN DOE

the order of

123 BRISTOL STREET

Type of payment is printed to the left of the amount.

HAWKINS BRANCH TX 76543

NOT NEGOTIABLE

’: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.