Washington Direct Deposit Form 2

FOR SALE BY THE SUPERINTENDENT OF DOCUMENTS, US GOVERNMENT PRINTING OFFICE
WASHINGTON, DC 20402 STOCK NO 048-000-00363-0
Standard Form 1199A
(Rev. June 1987)
Prescribed by Treasury Department
Treasury Dept. Cir. 1076
OMB No. 1510-0007
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
•
To sign up for Direct Deposit, the payee is to read the back of
this 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.
•
A separate form must be completed for each type of payment to
be sent by Direct Deposit.
•
The claim number and type of payment are printed on
Government checks. (See the sample check on the back of this
form). This information is also stated on beneficiary/annuitant
award letters and other documents from the Government
agency.
•
Payees must keep the Government agency informed of an
address changes in order to receive important information about
benefits and to remain qualified for payments.
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
STATE
ZIP CODE
F TYPE OF PAYMENT (Check only one)
Social Security
TELEPHONE NUMBER
AREA CODE
B NAME OF PERSON(S) ENTITLED TO PAYMENT
Fed Salary/Mil. Civilian Pay
Supplemental Security Income
Mil. Active:
Railroad Retirement
Mil. Retire.:
Civil Service Retirement (OPM)
Mil. Survivor:
VA Compensation or Pension
Other:
(specify)
C CLAIM OR PAYROLL ID NUMBER
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
CHECK
DIGIT
ROUTING NUMBER
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.
GOVERNMENT AGENCY COPY
FINANCIAL INSTITUTION COPY
PAYEE(S) COPY
BURDEN ESTIMATE STATEMENT
The estimated average burden associated with this collection of information is 10 minutes per respondent or
record-keeper, 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, Facilities Management
Division, Property & Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of
Management and Budget, Paperwork Reduction project (1510-0007), Washington, D.C. 20503.
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, C, and F in Section 1 is
printed on your government check:
A
Be sure that payee's name is written exactly as it
appears on the check. Be sure current address is
shown.
C
Claim numbers and suffixes are printed here on
checks beneath the date for the type of payment
shown here. Check the Green Book for the location
of prefixes and suffixes for other types of payments.
F Type of payment is printed to the left of the amount.
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.