Maryland Direct Deposit Form 3

Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. August 2012)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
checks. (See the sample check on the back of this form.) This
and fill in the information requested in Sections 1 and 2. Then take or
information is also stated on beneficiary/annuitant award letters and
mail this form to the financial institution. The financial institution will
other documents from the Government agency.
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Payees must keep the Government agency informed of any address
identified below.
changes in order to receive important information about benefits and to
remain qualified for payments.
A separate form must be completed for each type of payment to be
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
B
STATE
ZIP CODE
F TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
AMOUNT
Suffix
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 institution named below
to be deposited to the designated account.
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
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
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.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 7540-01-058-0224
GOVERNMENT AGENCY COPY
Reset
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. August 2012)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
checks. (See the sample check on the back of this form.) This
and fill in the information requested in Sections 1 and 2. Then take or
information is also stated on beneficiary/annuitant award letters and
mail this form to the financial institution. The financial institution will
other documents from the Government agency.
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Payees must keep the Government agency informed of any address
identified below.
changes in order to receive important information about benefits and to
remain qualified for payments.
A separate form must be completed for each type of payment to be
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
B
STATE
ZIP CODE
F TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
AMOUNT
Suffix
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 institution named below
to be deposited to the designated account.
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
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
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.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 7540-01-058-0224
FINANCIAL INSTITUTION COPY
Reset
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. August 2012)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
checks. (See the sample check on the back of this form.) This
and fill in the information requested in Sections 1 and 2. Then take or
information is also stated on beneficiary/annuitant award letters and
mail this form to the financial institution. The financial institution will
other documents from the Government agency.
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Payees must keep the Government agency informed of any address
identified below.
changes in order to receive important information about benefits and to
remain qualified for payments.
A separate form must be completed for each type of payment to be
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
B
STATE
F TYPE OF PAYMENT (Check only one)
ZIP CODE
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
AMOUNT
Suffix
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 institution named below
to be deposited to the designated account.
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
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
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.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 7540-01-058-0224
PAYEE COPY
Reset
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
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
Section 1 is printed on your government check:
United States Treasury
Month Day Year
08
31
84
15-51
000
KANSAS CITY, MO
28
A Be sure that payee’s name is written exactly as it
appears on the check. Be sure current address is shown.
F Type of payment is printed to the left of the amount.
Pay to
the order of
Check No.
0000 415785
28
VA COMP
JOHN DOE
123 BRISTOL STREET
HAWKINS BRANCH TX 76543
A
DOLLARS
CTS
$****100
00
F
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.