BURDEN ESTIMATE STATEMENT
The estimated average burden associated with this collection of information is 10 minutes per respondent or record-
keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and sug-
gestions for reducing this burden should be directed to the Financial Management Service, Facilities Management
Division, Property& Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office
of Management and Budget, Paperwork Reduction Project (1510-0007), Washington, D.C. 20503.
PLEASE READ THIS CAREFULLY
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 confidential and is needed to prove entitlement to
payments. The information will be used to process payment data from the Federal agency to the finan-
cial institution and/or its agent. Failure to provide the requested information may affect the process-
ing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Elec-
tronic Funds Transfer Program.
INFORMATION FOUND ON CHECKS
Most of the information needed to complete
boxes A, C, andF in Section1 is printed on your
A Be sure that the payee’s name is written exactly as it ap-
pears on the check. Be sure current address is shown.
Claim numbers and suffixes are printed here on
checks beneath the date for the type of payment
shown here. Check the Green Book for the location
of prefixes and suffixes for other types of payments.
Type of payment is printed to the left of the amount.
United States Treasury
123 BRISTOL STREET
HAWKINS BRANCH, TX 76543
29-693-775 00 C
08 31 84
Month Day Year
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
Joint account holders should immediately advise both the Government agency and the finan-
cial institution of the death ofa beneficiary. 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 makea determination regarding survivor rights, calculate survivor benefit payments, if any,
and begin payments.
The agreement represented by this authorization remains in effect until canceled by the reci-
pient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancella-
tion by the recipient, the recipient should notify the receiving financial institution that he/she is
The agreement represented by this authorization may be cancelled by the financial institution
by providing the recipienta 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 financial institu-
tion. The financial institution cannot cancel the authorization by advice to the Government agency.
CHANGING RECEIVING FINANCIAL INSTITUTIONS
The payee’s Direct Deposit will continue to be received by the selected financial institution until
the Government agency is notified by the payee that the payee wishes to change the financial in-
stitution receiving the Direct Deposit. To effect this change, the payee will complete the new SF 1199A
at the newly selected financial institution. It is recommended that the payee maintain accounts at
both financial institutions until the transition is complete, i.e. after the new financial institution receives
the payee’s Direct Deposit payment.
FALSE STATEMENTS OR FRAUDULENT CLAIMS
Federal law providesa fine of not more than $10,000 or imprisonment for not more than five (5)
years or both for presentinga false statement or makinga fraudulent claim.