Fillable Form 1199a (Department of the Treasury - OCIO)

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Form 1199a (Department of the Treasury - OCIO)

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OMB No. 1530-0006
1199-207
Standard Form 1199A
(Rev. February 2020)
Prescribed by Treasury Department
T
reasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
SECTION 1 (TO BE COMPLETED BY PAYEE)
A
B
C
D
E
F
G
NAME OF PAYEE (last, rst, middle initial)
NAME OF PERSON(S) ENTITLED TO PAYMENT
CLAIM OR PAYROLL ID NUMBER
SIGNATURE
SIGNATURE
GOVERNMENT AGENCY NAME
NAME AND ADDRESS OF FINANCIAL INSTITUTION
PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
ROUTING NUMBER
DEPOSITOR ACCOUNT TITLE
CHECK
DIGIT
GOVERNMENT AGENCY ADDRESS
SIGNATURE
SIGNATURE
DATE
DATE
DATE
DATE
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION
I certify that I am entitled to the payment identied 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 nancial institution named below to be
deposited to the designated account.
I conrm the identity of the above-named payee(s) and the account number and title. As representative of the above-named nancial institution, I certify
that the nancial institution agrees to receive and deposit the payment identied above in accordance with 31 CFR Parts 240, 209, and 210.
I certify that I have read and understood the back of this form, including
the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
Prex Sux
TYPE OF DEPOSITOR ACCOUNT
DEPOSITOR ACCOUNT NUMBER
TYPE OF PAYMENT
(Check only one)
TYPE AMOUNT
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
(if applicable)
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
(specify)
CHECKING SAVINGS
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
FINANCIAL INSTITUTION CERTIFICATION
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.
GOVERNMENT AGENCY COPY
DIRECTIONS
To sign up for Direct Deposit, the payee is to read the back of this form
and ll in the information requested in Sections 1 and 2. Then take or
mail this form to the nancial institution. The nancial 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
identied 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 beneciary/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 benets and to
remain qualied for payments.
Reset
OMB No. 1530-0006
1199-207
Standard Form 1199A
(Rev. February 2020)
Prescribed by Treasury Department
T
reasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
SECTION 1 (TO BE COMPLETED BY PAYEE)
A
B
C
D
E
F
G
NAME OF PAYEE (last, rst, middle initial)
NAME OF PERSON(S) ENTITLED TO PAYMENT
CLAIM OR PAYROLL ID NUMBER
SIGNATURE
SIGNATURE
GOVERNMENT AGENCY NAME
NAME AND ADDRESS OF FINANCIAL INSTITUTION
PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
ROUTING NUMBER
DEPOSITOR ACCOUNT TITLE
CHECK
DIGIT
GOVERNMENT AGENCY ADDRESS
SIGNATURE
SIGNATURE
DATE
DATE
DATE
DATE
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION
I certify that I am entitled to the payment identied 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 nancial institution named below to be
deposited to the designated account.
I conrm the identity of the above-named payee(s) and the account number and title. As representative of the above-named nancial institution, I certify
that the nancial institution agrees to receive and deposit the payment identied above in accordance with 31 CFR Parts 240, 209, and 210.
I certify that I have read and understood the back of this form, including
the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
Prex Sux
TYPE OF DEPOSITOR ACCOUNT
DEPOSITOR ACCOUNT NUMBER
TYPE OF PAYMENT
(Check only one)
TYPE AMOUNT
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
(if applicable)
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
(specify)
CHECKING SAVINGS
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
FINANCIAL INSTITUTION CERTIFICATION
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.
FINANCIAL INSTITUTION COPY
DIRECTIONS
To sign up for Direct Deposit, the payee is to read the back of this form
and ll in the information requested in Sections 1 and 2. Then take or
mail this form to the nancial institution. The nancial 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
identied 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 beneciary/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 benets and to
remain qualied for payments.
Reset
OMB No. 1530-0006
1199-207
Standard Form 1199A
(Rev. February 2020)
Prescribed by Treasury Department
T
reasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
SECTION 1 (TO BE COMPLETED BY PAYEE)
A
B
C
D
E
F
G
NAME OF PAYEE (last, rst, middle initial)
NAME OF PERSON(S) ENTITLED TO PAYMENT
CLAIM OR PAYROLL ID NUMBER
SIGNATURE
SIGNATURE
GOVERNMENT AGENCY NAME
NAME AND ADDRESS OF FINANCIAL INSTITUTION
PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
ROUTING NUMBER
DEPOSITOR ACCOUNT TITLE
CHECK
DIGIT
GOVERNMENT AGENCY ADDRESS
SIGNATURE
SIGNATURE
DATE
DATE
DATE
DATE
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION
I certify that I am entitled to the payment identied 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 nancial institution named below to be
deposited to the designated account.
I conrm the identity of the above-named payee(s) and the account number and title. As representative of the above-named nancial institution, I certify
that the nancial institution agrees to receive and deposit the payment identied above in accordance with 31 CFR Parts 240, 209, and 210.
I certify that I have read and understood the back of this form, including
the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
Prex Sux
TYPE OF DEPOSITOR ACCOUNT
DEPOSITOR ACCOUNT NUMBER
TYPE OF PAYMENT
(Check only one)
TYPE AMOUNT
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
(if applicable)
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
(specify)
CHECKING SAVINGS
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
FINANCIAL INSTITUTION CERTIFICATION
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.
PAYEE COPY
DIRECTIONS
To sign up for Direct Deposit, the payee is to read the back of this form
and ll in the information requested in Sections 1 and 2. Then take or
mail this form to the nancial institution. The nancial 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
identied 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 beneciary/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 benets and to
remain qualied for payments.
Reset
A
C
F
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 Ocer, Parkersburg, WV
26106-1328.
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 condential 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 aect 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
check:
Joint account holders should immediately advise both the Government agency and the nancial institution of the death
of a beneciary. 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
benet payments, if any, and begin payments.
The agreement represented by this authorization remains in eect 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 notied by the payee that the payee wishes to change the nancial institution receiving the Direct Deposit. To eect 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.
15-51
:00000518’: 0415771926”
000
28
DOLLARS CTS
28
08 31 84
00
PHILADELPHIA, PA
Pay to
the order of
Check No.
0000 415785
Month Day Year
Claim numbers and suxes are printed here on checks
beneath the date for the type of payment shown here.
Check the Green Book for the location of prexes and
suxes 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
NOT NEGOTIABLE
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
CANCELLATION
CHANGING RECEIVING FINANCIAL INSTITUTIONS
FALSE STATEMENTS OR FRAUDULENT CLAIMS
A
C
F
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Form 1199a (Department of the Treasury - OCIO)

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Completed 22 July 2020

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