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Instructions For Completion Of The
DIRECT DEPOSIT SIGN-UP FORM (SF 1199A)
and the CONTACT INFORMATION FORM
for Non-HHS Grant Recipients
OVERVIEW
Grant Recipients must have established, active accounts in the Payment Management System (PMS) in order to
request authorized funds. The accounts are established in PMS once the completed SF-1199A and Contact
Information forms have been received by DPM.
It is the responsibility of the Awarding Agency to provide the requisite Direct Deposit Sign-Up Form (SF-1199A)
and DPM’s Contact Information Form to the grantee for completion. It is also the Awarding Agency’s
responsibility to ensure the accuracy of the forms’ information prior to forwarding them to DPM for processing.
Who must complete these forms?
SF-1199A - Section 1 is to be completed by the grant recipient. Section 2 is to be completed by the Awarding
Agency. Section 3 is to be completed by the recipient’s financial institution. More complete instructions can be
found on the next page.
The recipient must complete the Contact Information Form. The
Primary Contact on the form should be the
person responsible for requesting the funds.
How should the forms be disseminated?
The Awarding Agency should retain copies of the SF-1199A and Contact Information forms. The financial
institution will retain its copy of the SF-1199A. Both originals must be mailed to DPM at one of the addresses
below.
Include a cover memo stating that the accompanying SF-1199A form is being submitted to establish a NEW account
in the Payment Management System. The memo must include the name of the organization as it appears on the SF-
1199A. The memo can list more than one organization, but there can only be one organization per SF-1199A.
What if some of the information changes?
Should any of the data on the completed SF- 199A change, the recipient must obtain and complete a new 1199A.
Blank forms are available on the DPM website at
http://www.dpm.psc.gov and should be available at the recipient's
financial institution as well.
DIRECTIONS
The back of the 1199A must be read carefully before signatures are made.
All information is to be typed or printed in ink on the 1199A.
All signatures must be original and in ink.
Alterations such as erasures, correction fluid and strike-outs are unacceptable and will
invalidate the form.
All data elements on the 1199A must be completed unless a blank is indicated.
This form cannot be faxed.
Send to: Division of Payment Management
Regular Mail Only - PO Box 6021, Rockville, MD 20852.
Express Mail Only - 11400 Rockville Pike, Suite 700, Rockville, MD 20852.
Detailed Instruction for the Completion of the
Direct Deposit Sign-Up Form (SF 1199A)
For Non -HHS Grant Recipients
(Please Read This Carefully)
Section 1 (To be Completed by Payee)
A. Type or print your organization's name, address and telephone number. Do not enter an
individual's name in this block unless the grant was actually awarded to the individual.
Forms containing white out or any alterations to the payee name are unacceptable.
B. Type or print your organization’s name.
C. Claim or Payroll ID Number: The form cannot be processed without this information. Enter
your
Federal Employer Identification Number. This is your 9-digit tax ID number, issued by
the IRS.
D. Check type of Bank Account - "Checking" or "Savings".
E. Type the account number at your Financial Institution to which the funds will be "Direct
Deposited". Do not use white out or make any alterations to the account number.
F. Check the box "Other" and type the name of the Federal Awarding Agency.
G. Leave blank.
Payee Account Holder’s Certification: The individual(s) having signature authority for the bank
account must sign and date.
Other Required Information: At the top right-hand corner, please type or print “DUNS”
followed by your organization’s DUNS (Dun And Bradstreet Number)
Section 2 (Return completed “Awarding Agency” copy to the address below)
Enter the name and address of the person at your agency who will receive and review the Direct
Deposit Form before forwarding the form to DPM/Payment Management System.
Section 3 (To be completed by your Financial Institution)
The bank’s representative must sign the form and provide a telephone number for contact
purposes. The depositor account title must be filled in and
should match the payee name in most
cases. Maintain the payee(s) copy for your records. Note: Failure to complete
ALL portions of
this section will result in a delay of your organization being established in PMS.
New Grantees: please send all material to the Awarding Agency, not
the HHS/Division of Payment Management.
SIGN-UPFORM
StandardForm1199A OMBNo.1510-0007
(Rev.June1987)
PrescribedbyTreasury
Department
TreasuryDept.Cir.1076
DIRECTIONS
Tosignupfordirectdeposit,thepayeeistoreadthebackofthis
formandfillintheinformationrequestedinSections1and2.Then
takeormailthisformtothefinancialinstitution.Thefinancialin-
stitutionwillverifytheinformationinSections1and2,andwillcom-
pleteSection3.Thecompletedform willbereturnedtotheGovern-
mentagencyidentifiedbelow.
Aseparateformmustbecompletedforeachtypeofpaymenttobe
sentbyDirectDeposit.
documentsfromtheGovernmentagency.
tionisalsostatedonbeneficiary/annuitantawardlettersandother
TheclaimnumberandtypeofpaymentareprintedonGovernment
checks.(Seethesamplecheckonthebackofthisform.)Thisinforma-
changesinordertoreceiveimportantinformationaboutbenefitsand
toremainqualifiedforpayments.
PayeesmustkeeptheGovernmentagencyinformedofanyaddress
SECTION1 (TOBECOMPLETEDBYPAYEE)
SECTION2 (TOBECOMPLETEDBYPAYEEORFINANCIALINSTITUTION)
SECTION3 (TOBECOMPLETEDBYFINANCIALINSTITUTION)
(last,first,middleinitial)
(Checkonlyone)
(specify)
(optional)
(ifapplicable)
(street,route,P.O.Box,APO/FPO)
A
B
C
D
E
F
G
tifythatthefinancialinstitutionagreestoreceiveanddepositthepaymentidentifiedaboveinaccordancewith31 CFRParts240,209,and210.
Prefix
IcertifythatIamentitledtothepaymentidentifiedabove,andthatI IcertifythatIhavereadandunderstoodthebackofthisform,including
theSPECIALNOTICETOJOINTACCOUNTHOLDERS.
havereadandunderstoodthebackofthisform.InsigningthisformI
authorizemypaymenttobesenttothefinancialinstitutionnamed
belowtobedepositedtothedesignatedaccount.
Suffix
PAYEE/JOINTPAYEECERTIFICATION JOINTACCOUNTHOLDERS’CERTIFICATION
Iconfirmtheidentityoftheabove-namedpayee(s)andtheaccountnumberandtitle.Asrepresentativeoftheabove-n amedfinancialinstitution,Icer-
FinancialinstitutionsshouldrefertotheGREENBOOKforfurtherinstructions.
NSN7540-01-058-0224
1199-207
THEFINANCIALINSTITUTIONSHOULDMAILTHECOMPLETEDFORMTOTHEGOVERNMENTAGENCYIDENTIFIEDABOVE.
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
government check:
A Be sure that the payee’s name is written exactly as it ap-
pears on the check. Be sure current address is shown.
C
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.
F
Type of payment is printed to the left of the amount.
United States Treasury
15-51
000
AUSTIN, TEXAS
JOHN DOE
123 BRISTOL STREET
HAWKINS BRANCH, TX 76543
29-693-775 00 C
VA COMP
F
A
28 28
08 31 84
Month Day Year
$****100*00
DOLLARS CTS
NOT NEGOTIABLE
Pay to
theorder of
Check No.
0000-4157815
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.
CANCELLATION
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
doing so.
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.
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