Sign-Up Form for
You may also sign up online today at www.GoDirect.org
Direct Deposit
or call Go Direct toll free at1 (800) 333-1795
of Federal Benefit Payments
(for social security, railroad retirement board, or civil (non-military)
retirement payments only).
FMS Form 1200 (July 2006) OMB No. 1510-0007
DIRECTIONS
Please read the information on page2 before completing this form. You must complete boxes A, B,C and D.
Only complete this form to sign up for direct deposit if you are an individual, ora representative payee of an individual, who receives checks
for the following types of federal benefits: social security, supplemental security income, railroad retirement, or civil (non-military)
retirement. If you currently receive your payment by direct deposit you may not use this form. Please refer to page2 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 attacha voided personal check. If you are depositing intoa 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 completea separate form for each type of federal payment.
SUPPLEMENTAL SECURITY INCOME SOCIAL SECURITY
RAILROAD RETIREMENT
(specify below)
CIVIL (NON-MILITARY) RETIREMENT
(specify below)
Survivor
annuity
Retirement
annuity
Annuity
benefit
Unemployment
survivor benefit
For military, federal salary, veterans benefits or other federal payments
not available through Go Direct, please contact the paying agency
(see page2 fora partial list of paying agencies).
CLAIM NUMBER
CHECK NUMBER (YOUR MOST RECENT PAYMENT)
OR
AMOUNT OF YOUR MOST RECENT PAYMENT
$
AND
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 your Treasury check)
at left.
You must enter the amount
of your last payment.
either
or
must be entered
also
D. CERTIFICATION
I certify thatI am entitled to receive the payment identified above, and thatI 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 PartB 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
FOR JOINT ACCOUNT HOLDERS
I certify thatI 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
