Fillable Standard Form 1199a - Direct Deposit Sign-Up Form printable pdf download

Standard Form 1199A (EG)

OMB No. 1510-0007

(Rev. August 2012)

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 form

The claim number and type of payment are printed on Government

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.)

This

mail this form to the financial institution. The financial institution will

information is also stated on beneficiary/annuitant award letters and

verify the information in Sections 1 and 2, and will complete Section 3.

other documents from the Government agency.

The completed form will be returned to the Government agency

identified below.

Payees must keep the Government agency informed of any address

changes in order to receive important information about benefits and to

A separate form must be completed for each type of payment to be

remain qualified for payments.

sent by Direct Deposit.

SECTION 1 (TO BE COMPLETED BY PAYEE)

NAME OF PAYEE (last, first, middle initial)

TYPE OF DEPOSITOR ACCOUNT

CHECKING

SAVINGS

DEPOSITOR ACCOUNT NUMBER

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

CITY

STATE

ZIP CODE

TYPE OF PAYMENT (Check only one)

Social Security

Fed. Salary/Mil. Civilian Pay

Supplemental Security Income

Mil. Active

TELEPHONE NUMBER

Railroad Retirement

Mil. Retire.

AREA CODE

Civil Service Retirement (OPM)

Mil. Survivor

NAME OF PERSON(S) ENTITLED TO PAYMENT

ROTC

VA Compensation or Pension

Other

pecify)

CLAIM OR PAYROLL ID NUMBER

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

TYPE

AMOUNT

Prefix

Suffix

JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)

PAYEE/JOINT PAYEE CERTIFICATION

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,

read and understood the back of this form. In signing this form, I

including 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.

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

DATE

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

GOVERNMENT AGENCY NAME

GOVERNMENT AGENCY ADDRESS

DFAS

INDIANAPOLIS, INDIANA

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

NAME AND ADDRESS OF FINANCIAL INSTITUTION

CHECK

ROUTING NUMBER

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 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’S NAME

SIGNATURE OF REPRESENTATIVE

TELEPHONE NUMBER

DATE

Financial institutions should refer to the GREEN BOOK for further instructions.

Reset

THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.

NSN 7540-01-058-0224

GOVERNMENT AGENCY COPY

1199-207

Designed using Perform Pro, WHS/DIOR, Mar 97

Standard Form 1199a - Direct Deposit Sign-Up Form

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