Virginia Direct Deposit Form 2

Sign-Up Form for
Direct Deposit
You may also sign up online today at www.GoDirect.org
or call Go Direct toll free at 1 (800) 333-1795
of Federal Benefit Payments
(for social security, railroad retirement board, civil (non-military)
retirement payments or VA only).
FMS Form 1200 (July 2009) Previous versions obsolete
OMB No. 1510-0007
DIRECTIONS
Please read the information on page 2 before completing this form. You must complete boxes A, B, C, D, E and F.
Only complete this form to sign up for direct deposit if you are an individual, or a representative payee of an individual, who receives checks
for the following types of federal benefits: social security, supplemental security income, railroad retirement, civil (non-military)
retirement, or VA (compensation or pension only). If you currently receive your payment by direct deposit you may not use
this form. Please refer to page 2 for further instructions.
A. FEDERAL BENEFIT RECIPIENT INFORMATION
B. BANK OR CREDIT UNION INFORMATION
(print name[s] and address exactly as they appear on your benefit check)
NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)
REPRESENTATIVE PAYEE?
Yes
if yes, enter No
name at right
DEPOSITOR ACCOUNT TITLE (name[s] on account)
NAME OF REPRESENTATIVE PAYEE
Checking
ADDRESS (street, route, P.O. box, apartment number)
CITY (or APO/FPO)
** 9-DIGIT ROUTING NUMBER
(see sample check below)
ACCOUNT TYPE
STATE
ZIP CODE
Savings
** ACCOUNT NUMBER (see sample check below; do not include check number)
DAYTIME TELEPHONE NUMBER
(
) ___________ - _______________
SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS
(BENEFICIARY)
SAMPLE CHECK (bottom left corner)
C. TYPE OF PAYMENT (check only one)
SOCIAL SECURITY
** You may also attach a voided personal check. If you are depositing into a savings account, you
may need to contact your financial institution to obtain the routing and account numbers.
111999087
9876554321
ROUTING NUMBER
ACCOUNT NUMBER
0001
CHECK NUMBER
You must complete a separate form for each type of federal payment.
SUPPLEMENTAL SECURITY INCOME
VA (COMP/PENSION ONLY)
For military, federal salary, veterans benefits or other federal payments
not available through Go Direct, please contact the paying agency
(see page 2 for a partial list of paying agencies).
RAILROAD RETIREMENT
(specify below)
Annuity
Unemployment
benefit
survivor benefit
D. IDENTIFICATION
CIVIL (NON-MILITARY) RETIREMENT
(specify below)
Survivor
Retirement
annuity
annuity
E. PAYMENT VERIFICATION
CLAIM NUMBER
OR
CHECK NUMBER (YOUR MOST RECENT PAYMENT)
In order to process your request, either the claim
number (found on documents from your paying
agency) or the check number from your last
payment (found in the upper right-hand corner
of your Treasury check) must be entered at left.
You must also enter the amount
of your last benefit payment.
AMOUNT OF YOUR MOST RECENT PAYMENT
$
F. CERTIFICATION
I certify that I am entitled to receive the payment identified above, and that I have
read and understand the back of this form. In signing this form, I authorize this
payment to be sent to the financial institution named in Part B above, to be
deposited into the account above.
FOR JOINT ACCOUNT HOLDERS
SIGNATURE
SIGNATURE
DATE
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS on the back of this form.
DATE
Be sure to complete all sections of this form.
Otherwise, the form cannot be processed.
Return the completed form to:
This form is only to be used for switching from check payments to direct deposit of certain federal
benefits listed in Box C. Use of this form for any other purposes will result in the form being rejected.
Go Direct Processing Center
U.S. Department of the Treasury
P.O Box 650527
Dallas, TX 75265-0527
Contact your paying agency to:
Update your name or address
Change your account information if you already receive your payment by direct deposit, or
Sign up for direct deposit for military, federal salary, veterans benefits, or other federal
payments not processed by Go Direct
PLEASE READ THIS CAREFULLY
PRIVACY ACT NOTICE
Your social security number and the other information requested will allow the federal government to make payments to you by
direct deposit. This collection of information is authorized by Title 31 of the United States Code, Section 3332(g). Also, Executive
Order 9397, November 22, 1943, authorizes the use of your social security number. 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 or another disbursing official to process federal payments to
you by direct deposit. This information may also be disclosed to a court, congressional committee or another government agency as
authorized or required by federal law and to your financial institution to verify receipt of your federal payments. Although providing
the requested information is voluntary, your direct deposit payment may be delayed or Treasury may be unable to send it if you fail
to provide the information.
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
If your account is a joint account and receives direct deposit benefit payments, you must inform the federal agency and the financial
institution of the death of a beneficiary. Payments sent by direct deposit after the date of death or ineligibility of a beneficiary (except
for salary payments) must be returned to the federal agency. The federal agency will then determine if the survivor is eligible for
benefits.
CANCELLATION
Your payment will be sent by direct deposit until the federal agency that issues the payments is notified to cancel, such as in the case of
death or legal incapacity of the person receiving the payment.
Your financial institution may cancel your direct deposit authorization. Your financial institution is required to give you written notice
30 days in advance of the cancellation date. If this occurs, you must notify the federal agency that the direct deposit authorization
was cancelled.
Please contact your paying agency to:
Update your name or address
Change your account information if you already receive your payment by direct deposit, or
Sign up for direct deposit for military, federal salary, veterans benefits, or other federal
payments not processed by Go Direct
Department of Veterans Affairs
(877) 838-2778
(800) 827-1000
(800) 829-4833 TDD
Railroad Retirement Board
(Automated System)
(877) 772-5772
(312) 751-4701 TTY
Social Security Administration
(800) 772-1213
(800) 325-0778 TTY
Office of Personnel Management
(888) 767-6738
(800) 878-5707 TDD
BURDEN ESTIMATE STATEMENT
The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the
burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information
Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED
FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT
SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.
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