FMS Form 1200 (July 2009) Previous versions obsolete OMB No. 1510-0007
You may also sign up online today at www.GoDirect.org
or call toll free at 1 (800) 333-1795Go Direct
F. CERTIFICATION
I certify that I am entitled to receive the payment identified above, and that I 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 Part B above, to be
deposited into the account above.
SIGNATURE DATE
A. FEDERAL BENEFIT RECIPIENT 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
B. BANK OR CREDIT UNION INFORMATION
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 attach a voided personal check. If you are depositing into a savings account, you
may need to contact your financial institution to obtain the routing and account numbers.
Sign-Up Form for
Direct Deposit
of Federal Benefit Payments
(for social security, railroad retirement board, civil (non-military)
retirement payments or VA ).only
FOR JOINT ACCOUNT HOLDERS
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS on the back of this form.
SIGNATURE DATE
C. TYPE OF PAYMENT (check only one) You must complete a separate form for each type of federal payment.
SUPPLEMENTAL SECURITY INCOME
SOCIAL SECURITY
CIVIL (NON-MILITARY) RETIREMENT
(specify below)
Survivor
annuity
Retirement
annuity
RAILROAD RETIREMENT
(specify below)
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 page 2 for a partial list of paying agencies).
SAMPLE CHECK (bottom left corner)
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
This form is 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.
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
only
Contact your paying agency to:
Go Direct
DIRECTIONS
Please read the information on page 2 before completing this form. You must complete boxes A, B, C, D, E and F.
Only complete this form to sign up for direct deposit if you are an individual, or a representative payee of an individual, who receives checks
for the following types of federal benefits: social security, supplemental security income, railroad retirement, civil (non-military)
retirement, or VA (compensation or pension only). If you currently receive your payment by direct deposit you may not use
this form. Please refer to page 2 for further instructions.
111999087 9876554321 0001
ROUTING NUMBER ACCOUNT NUMBER
CLAIM NUMBER
CHECK NUMBER (YOUR MOST RECENT PAYMENT)
OR
CHECK NUMBER
VA (COMP/PENSION ONLY)
D. IDENTIFICATION
You must enter the amountalso
of your last benefit payment.
AMOUNT OF YOUR MOST RECENT PAYMENT
$
E. PAYMENT VERIFICATION
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.
either
or
must be entered
