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Standard Form 1199A (EG) OMB No. 151 M007 <br /> (Rev. June 198]) <br /> Prescribed erntby Treasury DIRECT DEPOSIT SIGN -UP FORM <br /> Department <br /> Treasury Dept. Cir. 1076 ' <br /> DIRECTIONS <br /> • To sign up for Direct Deposit, the payee is to read the back of this form o The claim number and type of payment are printed on Government <br /> and fill in the information requested in Sections 1 and 2. Then take or checks. (See the sample check on the back of this form.) <br /> This <br /> mail this form to the financial institution. The financial institution will information is also stated on beneficiary/annuitant award letters <br /> and <br /> verify the information in Sections 1 and 2, and will complete Section 3, other documents from the Government agency. <br /> The completed form will be returned to the Government agency <br /> identified below. • Payees must keep the Government agency informed of any address <br /> changes in order to receive important information about benefits and to <br /> • A separate form must be completed for each type of payment to be remain qualified for payments. <br /> sent by Direct Deposit. <br /> SECTION 1 (TO BE COMPLETED BY PAYEE) <br /> A NAME OF PAYEE (last, Fist, middle initial) D TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS <br /> E DEPOSITOR ACCOUNT NUMBER <br /> ADDRESS (street, route, P.O. Bax, APO/FPO) <br /> CITY STATE ZIP CODE F TYPE OF PAYMENT (Check onlyone) <br /> ❑ Social Security ❑ Fed. Salary/Mil. Civilian Pay <br /> TELEPHONE NUMBER <br /> El Supplemental Security Income ❑ Mil. Active <br /> ElRailroad Retirement ❑ Mil. Retire. <br /> AREA CODE <br /> B NAME OF PERSON(S) ENTITLED TO PAYMENT E] Civil Service Retirement (OPM) El mil. Survivor <br /> ❑ VA Compensation or Pension ❑ Other <br /> (specify) <br /> C CLAIM OR PAYROLL ID NUMBER G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (If applicable) <br /> TYPE AMOUNT <br /> Prefix Suffix <br /> PAYEEIJOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS' CERTIFICATION (optional) <br /> I certify that I am entitled to the payment identified above, and that I have I certify that I have read and understood the back of this form, <br /> read and understood the back of this form . In signing this form, I including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS. <br /> authorize my payment to be sent to the financial institution named below <br /> to be deposited to the designated account. <br /> SIGNATURE DATE SIGNATURE DATE <br /> SIGNATURE DATE SIGNATURE DATE <br /> SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION) <br /> GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS <br /> SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) <br /> NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK <br /> DIGIT <br /> DEPOSITOR ACCOUNT TITLE <br /> FINANCIAL INSTITUTION CERTIFICATION <br /> 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 <br /> certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and <br /> 210. <br /> PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE <br /> Financial institutions should refer to the GREEN BOOK for further instructions. <br /> THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE. <br /> NSN 754(1 058-=4 GOVERNMENT AGENCY COPY 1199.207 <br /> Designed using Perform Pro, MSIDIOR, Mar 97 <br />