Please refer to the information on the reverse side before completing this form. You must complete a separate form for each type of federal
payment (social security, supplemental security income, veterans’ benefits, etc.).
You are responsible for keeping the paying agency informed of any name or address changes. Return the completed form to the federal
agency from which you will be receiving Direct Deposit payments. Check the Government Listings Section of your local telephone directory for
the nearest office.
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If you elect to enroll by phone, the toll-free number may only be used for social security, railroad retirement or Office of Personnel
Management payments. You may also contact each agency individually at the toll-free number below. For veterans benefits and all other types
of federal payments, you must enroll directly through your paying agency either by phone or completing and mailing this form.
Go Direct
DIRECTIONS
TEST Standard Form 1199A
(August 2005)
Prescribed by Treasury Department
Treasury Department Cir. 1076
C. BANK OR CREDIT UNION INFORMATION
ACCOUNT TYPE
Checking Savings
** 9-DIGIT ROUTING NUMBER
(see sample check on reverse side)
** ACCOUNT NUMBER (see sample check on reverse side)
B. TYPE OF PAYMENT (check only one)
SUPPLEMENTAL SECURITY INCOME
SOCIAL SECURITY
D. 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 C above, to be
deposited into the account above.
SIGNATURE DATE
A. FEDERAL BENEFIT RECIPIENT INFORMATION
ADDRESS (street, route, P.O. box, apartment number)
CITY STATE ZIP CODE(or APO/FPO)
TELEPHONE NUMBER
( ) ___________ - _______________
SOCIAL SECURITY OR CLAIM NUMBER
(under which the current federal benefit payment is received)
OMB No. 1510-0007
ALLOTMENT ( )if applicable ( )___________________________________type
(a )________________________________mount
Or call at 1 (800) 333-1795
to sign up today.*
Go Direct
NAME OF LEGAL REPRESENTATIVE
Yes No
DEPOSITOR ACCOUNT TITLE (name[s] on account)NAME OF FEDERAL BENEFIT RECIPIENT
RAILROAD RETIREMENT
(specify below)
Annuity
benefit
Unemployment
survivor benefit
CIVIL SERVICE (OPM) RETIREMENT
(specify below)
Survivor
annuity
Retirement
annuity
MILITARY ( )specify below
Active Retired Survivor
(Military, Federal Salary, VA and
“Other” not available through )Go Direct
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
SM
REPRESENTATIVE PAYEE?
if yes, enter
name at right
** You may also attach a voided personal check.
VA COMPENSATION OR PENSION
OTHER ( ) ________________specify
FEDERAL SALARY
Railroad Retirement Board
Office of Personnel Management
(Automated System)
(800) 808-0772
(312) 751-4701 TTY
(888) 767-6738
(800) 878-5707 TDD
Department of Veterans Affairs
Social Security Administration
(877) 838-2778
(800) 827-1000
(800) 829-4833 TDD
(800) 772-1213
(800) 325-0778 TTY
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