SIGN-UP FORM

OMB No. 1510-0007
Expiration Date 1/31/90
STANDARD FORM 1199A
(Rev. 9/83)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
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
. The claim number and type of payment are printed on Government checks. (See the sample check
on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters
and other documents from the Government agency.
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section
3. The completed form will be returned to the Govern- ment agency identified below.
.
must keep the Government agency informed of any address changes in order to receive
. Payees
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)
ADDRESS (street, route, P.O. box, APO/FPO)
CITY
STATE
B
TELEPHONE NUMBER
C
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
D
TYPE OF DEPOSITOR ACCOUNT
E
DEPOSITOR ACCOUNT NUMBER
F
ZIP CODE
G
Fed Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
SAVINGS
TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
CLAIM OR PAYROLL ID NUMBER
CHECKING
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 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 cer- tify that the financial institution agress 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
1199-204
OMB No. 1510-0007
Expiration Date 1/31/90
STANDARD FORM 1199A
(Rev. 9/83)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
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
. The claim number and type of payment are printed on Government checks. (See the sample check
on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters
and other documents from the Government agency.
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section
3. The completed form will be returned to the Govern- ment agency identified below.
.
must keep the Government agency informed of any address changes in order to receive
. Payees
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)
ADDRESS (street, route, P.O. box, APO/FPO)
CITY
STATE
B
TELEPHONE NUMBER
C
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
D
TYPE OF DEPOSITOR ACCOUNT
E
DEPOSITOR ACCOUNT NUMBER
F
ZIP CODE
G
Fed Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
SAVINGS
TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
CLAIM OR PAYROLL ID NUMBER
CHECKING
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 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 cer- tify that the financial institution agress 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
1199-204
OMB No. 1510-0007
Expiration Date 1/31/90
STANDARD FORM 1199A
(Rev. 9/83)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
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
. The claim number and type of payment are printed on Government checks. (See the sample check
on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters
and other documents from the Government agency.
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section
3. The completed form will be returned to the Govern- ment agency identified below.
.
must keep the Government agency informed of any address changes in order to receive
. Payees
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)
ADDRESS (street, route, P.O. box, APO/FPO)
CITY
STATE
B
TELEPHONE NUMBER
C
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
D
TYPE OF DEPOSITOR ACCOUNT
E
DEPOSITOR ACCOUNT NUMBER
F
ZIP CODE
G
Fed Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
SAVINGS
TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
CLAIM OR PAYROLL ID NUMBER
CHECKING
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 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 cer- tify that the financial institution agress 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(S) COPY
1199-204