Fillable Printable Direct Deposit Sign Up Form

Direct Deposit Sign Up Form

FMS Form 1200 (July 2009) Previous versions obsoleteOMB No. 1510-0007

You may also sign up online today at www.GoDirect.org

or calltoll free at 1 (800) 333-1795Go Direct

F.CERTIFICATION

I certify that I am entitled to receive the payment identified above, and that I have

read and understand the back of this form. In signing this form, I authorize this

payment to be sent to the financial institution named in Part B above, to be

deposited into the account above.

SIGNATUREDATE

A. FEDERALBENEFIT RECIPIENT INFORMATION

(print name[s] and address exactly as they appear on your benefit check)

ADDRESS (street, route, P.O. box, apartment number)

CITYSTATEZIP CODE(orAPO/FPO)

DAYTIME TELEPHONE NUMBER

() ___________ - _______________

SOCIALSECURITY NUMBER OF PERSON ENTITLEDTO GOVERNMENTBENEFITS

(BENEFICIARY)

NAME OF REPRESENTATIVE PAYEE

YesNo

NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)

REPRESENTATIVE PAYEE?

if yes, enter

name at right

B. BANK OR CREDIT UNION INFORMATION

ACCOUNTTYPE

CheckingSavings

** 9-DIGIT ROUTING NUMBER

(see sample check below)

**ACCOUNT NUMBER (see sample check below; do not include check number)

DEPOSITORACCOUNTTITLE (name[s] on account)

** You may also attach a voided personal check. If you are depositing into a savings account, you

may need to contact your financial institution to obtain the routing and account numbers.

Sign-Up Form for

Direct Deposit

of Federal Benefit Payments

(for social security, railroad retirement board, civil (non-military)

retirement payments or VA).only

FOR JOINTACCOUNT HOLDERS

I certify that I have read the SPECIALNOTICE TO JOINTACCOUNT

HOLDERS on the back of this form.

SIGNATUREDATE

C. TYPE OF PAYMENT(check only one)You must complete a separate form for each type of federal payment.

SUPPLEMENTAL SECURITYINCOME

SOCIALSECURITY

CIVIL(NON-MILITARY) RETIREMENT

(specify below)

Survivor

annuity

Retirement

annuity

RAILROAD RETIREMENT

(specify below)

Annuity

benefit

Unemployment

survivor benefit

For military, federal salary, veterans benefits or other federal payments

not availablethrough Go Direct, please contact the paying agency

(see page 2 for a partial list of paying agencies).

SAMPLE CHECK (bottom left corner)

Be sure to complete all sections of this form.

Otherwise, the form cannot be processed.

Return the completed form to:

Go Direct Processing Center

U.S. Department of the Treasury

P.O Box 650527

Dallas, TX 75265-0527

This form isto be used for switching from check payments to direct deposit of certain federal

benefits listed in Box C. Use of this form for any other purposes will result in the form being rejected.

Update your name or address

Change your account information if you already receive your payment by direct deposit, or

payments not processed by

only

Contact your paying agency to:

Go Direct

DIRECTIONS

Please read the information on page 2 before completing this form. You must complete boxesA, B, C, D, E and F.

Only complete this form to sign up for direct deposit if you are an individual, or a representative payee of an individual, who receives checks

for the following types of federal benefits: social security, supplemental security income, railroad retirement, civil (non-military)

retirement, or VA(compensation or pension only). If you currently receive your payment by direct deposit you may not use

this form. Please refer to page 2 for further instructions.

11199908798765543210001

ROUTING NUMBERACCOUNT NUMBER

CLAIM NUMBER

CHECK NUMBER (YOUR MOST RECENTPAYMENT)

CHECK NUMBER

VA(COMP/PENSION ONLY)

D. IDENTIFICATION

You mustenter the amountalso

of your last benefit payment.

AMOUNT OFYOUR MOST RECENTPAYMENT

E. PAYMENT VERIFICATION

In order to process your request,the claim

number (found on documents from your paying

agency)the check number from your last

payment (found in the upper right-hand corner

of yourTreasury check)at left.

either

must be entered

PLEASE READ THIS CAREFULLY

PRIVACYACT NOTICE

SPECIALNOTICE TO JOINTACCOUNT HOLDERS

CANCELLATION

Your social security number and the other information requested will allow the federal government to make payments to you by

direct deposit.This collection of information is authorized by Title 31 of the United States Code, Section 3332(g).Also, Executive

Order 9397, November 22, 1943, authorizes the use of your social security number. Your social security number is requested to

ensure the accurate identification and retention of records pertaining to you and to distinguish you from other recipients of federal

payments.

This information will be disclosed to the Department of theTreasury or another disbursing official to process federal payments to

you by direct deposit.This information may also be disclosed to a court, congressional committee or another government agency as

authorized or required by federal law and to your financial institution to verify receipt of your federal payments.Although providing

the requested information is voluntary, your direct deposit payment may be delayed orTreasury may be unable to send it if you fail

to provide the information.

If your account is a joint account and receives direct deposit benefit payments, you must inform the federal agency and the financial

institution of the death of a beneficiary. Payments sent by direct deposit after the date of death or ineligibility of a beneficiary (except

for salary payments) must be returned to the federal agency.The federal agency will then determine if the survivor is eligible for

benefits.

Yourpaymentwillbesentbydirectdeposituntilthefederalagencythatissuesthepaymentsisnotifiedtocancel,suchasinthecaseof

deathorlegalincapacityofthepersonreceivingthepayment.

Your financial institution may cancel your direct deposit authorization.Your financial institution is required to give you written notice

30 days in advance of the cancellation date. If this occurs, you must notify the federal agency that the direct deposit authorization

was cancelled.

BURDEN ESTIMATE STATEMENT

The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper,

depending on individual circumstances.Comments concerning the accuracy of this time estimate and suggestions for reducing the

burden should be directed to the Financial Management Service,Administrative Programs Division, Records and Information

Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD 20782.THISADDRESS SHOULD ONLY BE USED

FOR COMMENTSAND/OR SUGGESTIONS CONCERNINGTHEAMOUNT OFTIME SPENT COLLECTINGTHE DATA. DO NOT

SENDTHE COMPLETED PAPERWORKTOTHEADDRESSABOVE FOR PROCESSING.

Railroad Retirement Board

Office of Personnel Management

(Automated System)

(877) 772-5772

(312) 751-4701TTY

(888) 767-6738

(800) 878-5707TDD

Department of VeteransAffairs

Social SecurityAdministration

(877) 838-2778

(800) 827-1000

(800) 829-4833TDD

(800) 772-1213

(800) 325-0778TTY

Please contact your paying agency to:

Go Direct

Update your name or address

Change your account information if you already receive your payment by direct deposit, or

payments not processed by

(2)