For official use only:
Customer Name
Case Number
FS Form 5396-1
Department of the Treasury
Bureau of the Fiscal Service
(Revised June 2016)
Direct Deposit Sign-Up Form Attachment
(May be used for up to four additional signatures.)
www.treasurydirect.gov
Attached to and made a part of Form:
Sign in ink.
Sign Here
(Signature of Applicant)
(Print Name)
Mailing Address
(Number and Street, Rural Route, or P.O. Box)
(Social Security Number)
(City/State/ZIP Code)
(Daytime Telephone Number)
E-Mail Address
Sign Here
(Signature of Applicant)
(Print Name)
Mailing Address
(Number and Street, Rural Route, or P.O. Box)
(Social Security Number)
(City/State/ZIP Code)
(Daytime Telephone Number)
E-Mail Address
Sign Here
(Signature of Applicant)
(Print Name)
Mailing Address
(Number and Street, Rural Route, or P.O. Box)
(Social Security Number)
(City/State/ZIP Code)
(Daytime Telephone Number)
E-Mail Address
Sign Here
(Signature of Applicant)
(Print Name)
Mailing Address
(Number and Street, Rural Route, or P.O. Box)
(Social Security Number)
(City/State/ZIP Code)
(Daytime Telephone Number)
E-Mail Address
RESET