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Standard Form 1199A

(Rev. June 1987) OMB No. 1510-0007

Prescribed by Treasury


DIRECT



DEPOSIT

SIGN-UP FORM
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

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)


A NAME OF PAYEE (last, first, middle initial)




D TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS


E DEPOSITOR ACCOUNT NUMBER


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


CITY STATE ZIP CODE




F TYPE OF PAYMENT (Check only one)

Social Security Fed Salary/Mil. Civilian Pay

Supplemental Security Income Mil. Active

Railroad Retirement Mil. Retire

Civil Service Retirement (OPM) Mil. Survivor

VA Compensation or Pension Other



(specify)



TELEPHONE NUMBER

AREA CODE







B NAME OF PERSON (S) ENTITLED TO PAYMENT



C CLAIM OR PAYROLL ID NUMBER (SSN)
Prefix Suffix

G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

TYPE


AMOUNT


PAYEE/JOINT PAYEE CERTIFICATION

I certify that I am entitled to the payment identified above, and that I have read and understood the back of this form. In signing this form, I authorize my payment to be sent to the financial institution named below to be deposited to the designated account.



JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
I certify that I have read and understood the back of this form, including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

SIGNATURE



DATE

SIGNATURE

DATE

DATE
SIGNATURE


SIGNATURE

DATE

SIGNATURE


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


GOVERNMENT AGENCY NAME

GOVERNMENT AGENCY ADDRESS

NAME AND ADDRESS OF FINANCIAL INSTITUTION



ROUTING NUMBER CHECK

DIGIT

DEPOSITOR ACCOUNT TITLE


FINANCIAL INSTITUTION CERTIFICATION

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 certify 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'S NAME

SIGNATURE OF REPRESENTATIVE

TELEPHONE NUMBER

DATE
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

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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