firstnet auth form

FIRST CITIZENS BANK
ALLOTMENT SAVINGS ACCOUNT APPLICATION AND TRANSFER AUTHORIZATION
INSTRUCTIONS
You will need the following information to complete these forms
1. Payment amount (including transfer fee)
2. Loan ID / Contract number
STEP 1
Part One (Half Page) – is the Allotment Savings Account Application and Transfer Authorization.
Please complete all the information and return this to:
FirstNet
P.O. Box 988
OR FAX TO: (270) 351-1239
Radcliff, KY 40159
Be sure to retain a copy for your records.
STEP 2
Part two is the Standard Form 1199a “Direct Deposit Sign Up Form.” Please use the routing number
and account number contained on this form to start your allotment.
A
DIVISION OF FIRST CITIZENS BANK
E L I Z A B E T H T O W N, K E N T U C K Y U S A
SSN
TIN
469
10
COMPANY CODE
SUB CODE
FIRST CITIZENS BANK
CONTRACT #
FIRSTNET
ALLOTMENT SAVINGS ACCOUNT APPLICATION AND TRANSFER AUTHORIZATION
In consideration of the opening and maintenance of a savings account by First citizens Bank the depositor agrees that this account shall be subject to the bank’s rules and
regulations covering allotment savings acc ount interest rates, statements and maintenance of this type account. Accounts inactive for 365 days may be assessed a
dormant service charge.
3.00 service charge)
Undersigned hereby authorizes First Citizens Bank to deduct from said account and transfer each month the amount of $_____________ (includes $_______
or any lesser amount if the first amount is not available to FirstNet. Electronic Fund Transfer disclosure and rules and regulations regarding this account will be mailed by First
Citizens Bank. Quarterly statements and other disclosures will be made available to you at firstnetbillpay.com. If the email address given is invalid, omitted or email is
returned to us we will automatically mail all disclosures and quarterly statements to the address given below. The owners of the accounts, by signing below consent,
to receive all required statements and disclosures, for example change-in-terms notices, Regulation E notice, error resolution procedures, electronically from First
Citizens Bank.
Under penalties of perjury, I certify that (1) the TIN provided on this form is true, correct and complete, and (2) that I am not subject to backup withholding either because (a) I
have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or (b) the IRS has notified me that I am no longer subject
to backup withholding.
CERTIFICATION INSTRUCTIONS: You must cross out item (a) above if the IRS notified you that you are currently subject to backup withholding because of under reporting
interest or dividends on your tax return.
X
TYPE OR PRINT
CLEARLY
Date
Signature
ACCOUNT HOLDER NAME (LAST, FIRST, MI)
X
TYPE OF DEPOSITOR ACCOUNT
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY
ALLOTMENT
SAVINGS
DEPOSITOR ACCOUNT NUMBER (SSAN plus Company Code)
469
STATE
ZIP CODE
TYPE OF PAYMENT (Check only one)
Fed Salary/Mil. Civilian Pay
Social Security
TELEPHONE NUMBER
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
AREA CODE
X Mil. Active
VA Compensation or Pension
Mil. Retire.
Mil. Survivor
Other
(specify)
Email Address
DATE OF BIRTH
MONTHLY
DEPOSIT
SSN
AMOUNT
$
BANK COPY
RESET
469
X
$
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, 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 the 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 B ook for the locati on
of prefixes and suffixes for other types of payments.
UnitedStatesTreasury
Month
08
Pay to
theorder of
Day
Year
15-51
000
Check No.
0000 - 4157815
AUSTIN, TEXAS
31 84
29-693-775
00
DOLLARS
C
28
JOHN DOE
123 BRISTOL STREET
HAWKINS BRANCH, TX 76543
CTS
28
VA COMP
$****100 * 00
F
A
NOT NEGOTIABLE
F Type of payment i s print ed to the l ef t o f 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 canceled 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 the 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.