DIRECT DEPOSIT SIGN

INSTRUCTIONS FOR COMPLETING THE
“DIRECT DEPOSIT SIGN-UP FORM”
Do not change any pre-printed information on the form
SECTION 1 information to complete:
A. Your name, Address and Telephone Number.
B. Leave “B” blank.
C. Write your Social Security Number in “C”.
D. Write the amount of the premium in “G”:
Option A = $11
Option B = $13
Option C = $14
Option D = $15
Sign and date the form on the left under “PAYEE/JOINT PAYEE CERTIFICATION”
Take or send the original form to your payroll office or use this information to
start your allotment under Employee Express, My Pay, or your Employee
Personal Page (EPP).
You must still complete an Enrollment Form and submit it to Mass Benefits
either by Fax: 703-642-2240; e-mail: [email protected]; or mail:
Mass Benefits Consultants, Inc.
PO Box 828
Annandale, VA 22003
Any questions? Call toll-free 800-221-3083.
DIRECT DEPOSIT
SIGN-UP FORM
DIRECTIONS
* To sign up for Direct Deposit, the payee is to fill in the
information requested in Sections 1 and 2. Then take or mail the
form to your payroll office.
* 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. This information is also stated on the
beneficiary/annuitant award letters and other documents from the
Government agency.
* Payees must keep the Government agency informed of any
address changes in order to receive important information about
benefits and remain qualified for payments.
SECTION 1 (TO BE COMPLETED BY PAYEE)
A NAME OF PAYEE (last, first, middle initial)
D TYPE OR DEPOSITOR ACCOUNT CHECKING SAVINGS
X
E DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, etc.)
7
0
0
3 3 3 0 7
CITY STATE ZIPCODE
F TYPE OF PAYMENT (Check only one)
Social Security
X Fed Salary/ Mil. Civilian Pay
Supplemental Security Inc
Mil. Active ______________
Railroad Retirement
Mil. Retired _____________
Civil Service Retire (OPM)
Mil. Survivor ____________
VA Compensation or Pension Other _________________
TELEPHONE NUMBER
AREA CODE
B NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Prefix Suffix
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
CHECKING
AMOUNT $
TYPE
PAYEE/JOINT PAYEE CERTIFICATION
I certify that I am entitled to the payment identified above, and that I have
read and understood this form. In signing this form, I authorize my
payment be sent to the financial institution named below to be deposited t
the designated account.
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
UNITED BANK
4230 John Marr Drive
ANNANDALE, VA 22003
ROUTING NUMBER
0
5 6 0
0
CHECK DIGIT
4
4
4
5
DEPOSITOR ACCOUNT TITLE
MASS BENEFITS CONSULTANTS, INC.
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-name 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.
NSN 7540-01-058-0224
GOVERNMENT AGENCY COPY
1199-20