Washington Direct Deposit Form 3

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
SIGN-UP FORM
DIRECTIONS
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.
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.
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 .
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 PAYE E (last, first, middle initial)
D TYPE OF DEPOSITOR ACCOUNT
SAVINGS
E DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY
CHECKING
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
B NAME OF PERSON(S) ENTITLED TO PAYMENT
✘
Fed Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire
Mil. Survivor
Other FEDERAL PAYMENT
(specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONL Y(if applicable)
C CLAIM OR PAYROLL ID NUMBER
TYPE
Prefix
FED TAX ID:
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 ead r
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
USDA Natural Resources Conservation Service
60 Quaker Lane, Suite 46
Warwick, RI 02886 FAX: 401-828-0433
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 itle. As
t representative of the above-named financial institution, I certify t at theh
financial institution agrees to receive and deposit the payment identified abo e in accordance
v
with 31 CFR Parts 240, 209, and 210.
PRINT OR TYPE REPRESENTATIVE'S NAME
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
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.
Clear Form
DATE
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
NOT NEGOTIABLE
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 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.