SF 1199A (Back)
The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper,
depending on individual circums tances. Comments concerning the accuracy of this burden esimates and suggestions for
reducing this burden should be directed to the Bureau of the Fiscal Service, Forms Management Ocer, Parkersburg, WV
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 condential and is needed to prove entitlement to payments. The information will be used to
process payment data from the Federal agency to the nancial institution and/or its agent. Failure to provide the requested
information may aect the processing of this form and may delay or prevent the receipt of payments through the Direct
Deposit/Electronic Funds Transfer Program.
Most of the information needed to complete boxes
A, C, and F in Section 1 is printed on your government
Joint account holders should immediately advise both the Government agency and the nancial institution of the death
of a beneciary. 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
benet payments, if any, and begin payments.
The agreement represented by this authorization remains in eect 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 nancial institution that he/she is doing so.
The agreement represented by this authorization may be cancelled by the nancial 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 nancial institution. The nancial institution cannot cancel the authorization by advice
to the Government agency.
The payee’s Direct Deposit will continue to be received by the selected nancial institution until the Government agency
is notied by the payee that the payee wishes to change the nancial institution receiving the Direct Deposit. To eect this
change, the payee will contact the paying agency with updated nancial account information. It is recommended that the
payee maintain accounts at both nancial institutions until the transaction is complete, i.e. after the new nancial institution
receives the payee’s Direct Deposit payment.
Federal law provides a ne of not more than $10,000 or imprisonment for not more than ve (5) years or both for
presenting a false statement or making a fraudulent claim.
Be sure that payee’s name is written exactly as it appears
on the check. Be sure current address is shown.
08 31 84
the order of
Month Day Year
Claim numbers and suxes are printed here on checks
beneath the date for the type of payment shown here.
Check the Green Book for the location of prexes and
suxes for other types of payments.
Type of payment is printed to the left of the amount.
BURDEN ESTIMATE STATEMENT
PLEASE READ THIS CAREFULLY
INFORMATION FOUND ON CHECKS
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
CHANGING RECEIVING FINANCIAL INSTITUTIONS
FALSE STATEMENTS OR FRAUDULENT CLAIMS