Fillable DIRECT DEPOSIT Sign-Up Form OMB No. 1510-0007 Standard (National Interagency Fire Center)

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DIRECT DEPOSIT Sign-Up Form OMB No. 1510-0007 Standard (National Interagency Fire Center)

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File type: PDF

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___________
_______________
of person entitled to payment)
NAME OF PERSON ENTITLED TO PAYMENT
(last, first,
middle initial)
YOUR NAME (if different from above)
YOUR ADDRESS (street, route, P.O. box, apartment number)
CITY (or APO/FPO) STATE ZIP CODE
YOUR TELEPHONE NUMBER
( )
SOCIAL SECURITY NUMBER OR CLAIM NUMBER (of person entitled to payment)
DIRECT DEPOSIT
OMB No. 1510-0007
Sign-Up Form
Standard Form 1199A
(Rev. Feb. 2005)
Prescribed by Treasury Department
Treasury Department Cir. 1076
A.
PERSON TO RECEIVE
PAYMENT
C.
BANK OR CREDIT UNION
INFORMATION
TYPE OF ACCOUNT
CHECKING
SAVINGS
9-DIGIT ROUTING NUMBER
(see sample check
on
reverse
side)
ACCOUNT NUMBER
(see reverse
side)
D.
CERTIFICATION
B.
TYPE
OF PAYMENT
(check
only one)
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 C above, to be
deposited into the account above.
SIGNATURE DATE
SOCIAL SECURITY
SUPPLEMENTAL SECURITY INCOME
RAILROAD RETIREMENT
CIVIL SERVICE RETIREMENT
VA COMPENSATION OR PENSION
OTHER (specify)
Casual Pay
FOR JOINT ACCOUNT HOLDERS
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS on the back of this form.
SIGNATURE DATE
DIRECTIONS
Please refer to the information on the reverse side before completing this form.
You must complete a separate form for each type of federal payment (social security, supplemental
security income, veterans' benefits, etc.).
You are responsible for keeping the paying agency informed of any name or address changes. Return
the completed form to the federal agency from which you will be receiving Direct Deposit payments.
National Interagency Fire Center
Casual Payment Center
A Service First Organization
CASUAL PAYMENT CENTER MS 270
3833 S DEVELOPMENT AVE BOISE, ID 83705-5354
PHONE: 877-471-2262 FAX 208-433-6405
PLEASE
READ THIS CAREFULLY
PRIVACY ACT NOTICE
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 the Treasury 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 or Treasury may be unable to send it if you fail to
provide the information.
SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS
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.
CANCELLATION
Your payment will be sent by Direct Deposit until the federal agency that issues the payments is notified to
cancel,
suchasinthecaseofdeathorlegalincapacityofthepaymentrecipient.
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. THIS ADDRESS SHOULD ONLY BE USED
FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT
SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.
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DIRECT DEPOSIT Sign-Up Form OMB No. 1510-0007 Standard (National Interagency Fire Center)

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Completed 10 August 2020

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