DIRECT DEPOSIT SIGN

Standard Form 1199A
OMB No. 1510-0007
(Rev. June 1987)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
SIGN-UP FORM
DIRECT DEPOSIT
• To sign up for Direct Deposit, the payee is to read the back of this
DIRECTIONS
• The claim number and type of payment are printed on Government
form and fill in the information requested in Sections 1 and 2. Then
take or mail this form to the financial institution. The financial institution will verify the information in Sections 1 and 2, and will complete Section 3. The completed form will be returned to the Government agency identified below.
checks. (See the sample check on the back of this form.) This
tion is also stated on beneficiary/annuitant award letters and other
documents from the Government agency.
•
• A separate form must be completed for each type of payment to be
Payees must keep the Government agency informed of any address
changes in order to receive important information about benefits and
to remain qualified for payments.
sent by Direct Deposit.
SECTION 1 (TO BE COMPLETED BY PAYEE)
A
D TYPE OF DEPOSITOR ACCOUNT
NAME OF PAYEE (last, first, middle initial)
STATE
ZIP CODE
F TYPE OF PAYMENT (Check
C
only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
TELEPHONE NUMBER
AREA CODE
B
SAVINGS
E DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY
CHECKING
NAME OF PERSON (S) ENTITLED TO PAYMENT
Fed Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire
Mil. Survivor
Other
(Specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
CLAIM OR PAYROLL ID NUMBER (SSN)
Prefix
Suffix
TYPE
AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
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
I certify that I have read and understood the back of this form, including the SPECIAL NOTICE
institution named below to be deposited to the designated account.
TO JOINT ACCOUNT HOLDERS.
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
SIGNATURE
DATE
SIGNATURE
DATE
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
HEW FEDERAL CREDIT UNION
400 NORTH COLUMBUS
STREET Credit Union
Democracy
Federal
ALEXANDRIA, VA 22314
400 N Columbus St
Alexandria, VA 22314
2 5 4 0 7 4 6 8
8
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
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