DIRECT DEPOSIT SIGN-UP FORM

Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. June 1987)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
checks. (See the sample check on the back of this form.) This
and fill in the information requested in Sections 1 and 2. Then take or
information is also stated on beneficiary/annuitant award letters and
mail this form to the financial institution. The financial institution will
other documents from the Government agency.
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Payees must keep the Government agency informed of any address
identified below.
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 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
B
STATE
ZIP CODE
F TYPE OF PAYMENT (Check only one)
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
Social Security
Supplemental Security Income
Railroad Retirement
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Civil Service Retirement (OPM)
VA Compensation or Pension
Mil. Survivor
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
N/A
SIGNATURE
DATE
N/A
SIGNATURE
DATE
N/A
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
State Department Federal Credit Union
1630 King Street
Alexandria VA 22314-2745
CHECK
DIGIT
ROUTING NUMBER
2 5
6 0 7 5 3 4
2
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.
NSN 7540-01-058-0224
GOVERNMENT AGENCY COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97