Fillable Printable Direct Deposit Sign-Up Form - SSA

Direct Deposit Sign-Up Form - SSA

Standard Form 1199A (EG)

(Rev. June 1987)

Prescribed by Treasury

Department

Treasury Dept. Cir. 1076

DIRECT DEPOSIT SIGN-UP FORM

OMB No. 1510-0007

DIRECTIONS

To sign up for Direct Deposit, the payee is to read the back of this form

and fill in the information requested in Sections 1 and 2. Then take or

mail this form to the financial institution. The financial institution will

verify the information in Sections 1 and 2, and will complete Section 3.

The completed form will be returned to the Government agency

identified below.

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. (See the sample check on the back of this form.) This

information is also stated on 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 to

remain qualified for payments.

SECTION 1

(TO BE COMPLETED BY PAYEE)

NAME OF PAYEE

(last, first, middle initial)

ADDRESS

(street, route, P.O. Box, APO/FPO)

CITY STATE ZIP CODE

TELEPHONE NUMBER

AREA CODE

NAME OF PERSON(S) ENTITLED TO PAYMENT

CLAIM OR PAYROLL ID NUMBER

Prefix Suffix

TYPE OF DEPOSITOR ACCOUNT

CHECKING SAVINGS

DEPOSITOR ACCOUNT NUMBER

TYPE OF PAYMENT

(Check only one)

Social Security

Supplemental Security Income

Railroad Retirement

Civil Service Retirement (OPM)

VA Compensation or Pension

Fed. Salary/Mil. Civilian Pay

Mil. Active

Mil. Retire.

Mil. Survivor

Other

pecify)

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY

(if applicable)

TYPE AMOUNT

PAYEE/JOINT PAYEE CERTIFICATION

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.

JOINT ACCOUNT HOLDERS’ CERTIFICATION

(optional)

I certify that I have read and understood the back of this form,

including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

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

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

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 PAYEE COPY

1199-207

Designed using Perform Pro, WHS/DIOR, Mar 97

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:

Be sure that payee’s name is written exactly as it ap-

pears on the check. Be sure current address is shown.

Claim numbers and suffixes are printed here on checks

beneath the date for the type of payment shown here.

Check the Green Book for the location of prefixes and

suffixes for other types of payments.

Type of payment is printed to the left of 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 cancelled 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 a 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.

United States Treasury

15-51

000

AUSTIN, TEXAS

Check No.

0000 415785

Month Day Year

08 31

29-693-775 00

Pay to

the order of

JOHN DOE

123 BRISTOL STREET

HAWKINS BRANCH TX 76543

DOLLARS CTS

$****100 00

28 28

VA COMP

NOT NEGOTIABLE

’:00000518’: 041571926"

SF 1199A (Back)