Sign-Up Form for
You may also sign up online today at www.GoDirect.org
Direct Deposit
or call Go Direct toll free at 1 (800) 333-1795
(for social security, railroad retirement board, civil (non-military)
of Federal Benefit Payments
retirement payments or VA only).
FMS Form 1200 (July 2009) Previous versions obsolete OMB No. 1510-0007
DIRECTIONS
Please read the information on page 2 before completing this form. You must complete boxes A, 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.
A. FEDERAL BENEFIT RECIPIENT INFORMATION
B. BANK OR CREDIT UNION INFORMATION
(print name[s] and address exactly as they appear on your benefit check)
ADDRESS (street, route, P.O. box, apartment number)
CITY STATE ZIP CODE (or APO/FPO)
DAYTIME TELEPHONE NUMBER
( ) ___________ _______________ -
SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS
(BENEFICIARY)
NAME OF REPRESENTATIVE PAYEE
Yes No
NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)
REPRESENTATIVE PAYEE?
if yes, enter
name at right
ACCOUNT TYPE
Checking Savings
** 9-DIGIT ROUTING NUMBER
(see sample check below)
** ACCOUNT NUMBER (see sample check below; do not include check number)
DEPOSITOR ACCOUNT TITLE (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.
SAMPLE CHECK (bottom left corner)
111999087 9876554321 0001
ROUTING NUMBER ACCOUNT NUMBER CHECK NUMBER
C. TYPE OF PAYMENT (check only one) You must complete a separate form for each type of federal payment.
SOCIAL SECURITY
SUPPLEMENTAL SECURITY INCOME
VA (COMP/PENSION ONLY)
RAILROAD RETIREMENT CIVIL (NON-MILITARY) RETIREMENT
(specify below)
(specify below)
For military, federal salary, veterans benefits or other federal payments
Survivor
not available through Go Direct, please contact the paying agency
benefit
Annuity Unemployment
Retirement
annuity
annuity
survivor benefit
(see page 2 for a partial list of paying agencies).
D. IDENTIFICATION E. PAYMENT VERIFICATION
CLAIM NUMBER
In order to process your request,
either
the claim
You must also enter the amount
OR
number (found on documents from your paying
of your last benefit payment.
agency) or the check number from your last
CHECK NUMBER (YOUR MOST RECENT PAYMENT)
AMOUNT OF YOUR MOST RECENT PAYMENT
payment (found in the upper right-hand corner
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.
SIGNATURE DATE
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
of your Treasury check)
must be entered
at left.
$
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
This form is
only
to 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.
Contact your paying agency to:
Update your name or address
Change your account information if you already receive your payment by direct deposit, or
Sign up for direct deposit for military, federal salary, veterans benefits, or other federal
payments not processed by Go Direct
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