Fillable Rev 1199a DirectDeposit FORM SF-1199 Form and Instructions

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Rev 1199a DirectDeposit FORM SF-1199 Form and Instructions

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INSTRUCTIONS FOR COMPLETING THE
DIRECT DEPOSIT SIGN-UP FORM (SF
1199A) FOR A NEW GRANT RECIPIENT
Section 1 (To be Completed by Payee)
Box No. : Instruction D
etails
A.
Type or print your organization’s name, address, and telephone number.
Forms containing whi
te out or any alterations to the payee name are unacceptable.
B.
Type or print your grant agreement number. Do not enter an individual's
name in this block.
Forms containing t
he name of an individual in this box are unacceptable.
C.
This is your organization’s 9-digit Entity Identification Number (EIN) or your
organization’s Tax Identification Number (TIN).
The form cannot be processed without this information.
D. Check type
of Bank account "Checking" or "Savings".
E. Type the depositor account number at your Financial Institution to which the funds will be
"Directly 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 awarding Federal agency, (DOL/ETA).
G. Leave blank.
Payee Account Holder’s Certification: The individual(s) having signature authority for the bank
account should sign and date.
Section 2 (To be Completed by Payee) Already populated for you the awarding agency information:
U.S. Department of Labor – Employment and Training
Administration 200 Constitution Avenue, NW Rm. N-4702
Washington, DC 20210
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: If “ALL” portions of this section are not completed, this will cause a delay in your organization being
established in PMS.
COMPLETED FORMS SHOULD BE SENT VIA EMAIL, FAX, OR MAIL TO:
Linda Porter
Linda.Porter@psc.hhs.gov
Fax Numbers: 301-492-5096 or 301-492-4581
Payment Management Services
U.S. Department of Health and Human Services
P.O. Box 6021
Rockville, MD 20852
Attention: Linda Porter
Updated in January 2016
INSTRUCTIONS FOR EXISTING GRANT RECIPIENTS
WITH CHANGES TO BANKING OR PAYMENT MANAGEMENT SYSTEMS (PMS) USER
ACCESS INFORMATION
1. If
your organization has a change in banking information, address change, etc., you must comp
lete
a new Direct
Deposit Sign-Up Form (SF 1199A). The form can be found at the following:
http://www.doleta.gov/grants/payment_information.cfm
Please include a cover letter stating:
Current PMS account nu
mb
er
The reason for the new
SF 1199A Form (such as bank change or address change).
Please email, fax or mail the cover letter and completed SF 1199A to:
Linda Porter
Linda.Porter@psc.hhs.gov
Fax Numbers: 301-492-5096 or 301-492-4581
Payment Management Services
U.S. Department of Health and Human Services
P.O. Box 6021
Rockville, MD 20852
Attention: Linda Porter
2. If
you need to add a new user to your PMS account, please complete the Payment Manageme
nt
Sy
stem Access Form and email, fax, or mail the form to Payment Management Services. Please use
the web link and PMS contact information provided above.
3. A grantee
can only have one PMS account number such as D1234B1. However, a grantee may
have different bank information linked to the PMS account for different grants, such as one bank
account for HG12345W0 and another for PE12345G0. In this case, a grantee must submit a new
Direct Deposit Sign-Up Form (SF 1199A) and write on top of the form the specific grant number for
the designated bank account. Email, fax, or mail the SF 1199A Form to the same address as provided
above.
Standard Form 1199A (EG)
(Rev. June 1987)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
OMB No. 1510-0007
DIRECTIONS
To sign up for Direct Deposit, the payee is to read the back of this form
and fill in the information requested in Sections 1 and 2. Then take or
mail this form to the financial institution. The financial institution will
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
identified below.
A separate form must be completed for each type of payment to be
sent by Direct Deposit.
The claim number and type of payment are printed on Government
checks. (See the sample check on the back of this form.) This
information is also stated on beneficiary/annuitant award letters and
other documents from the Government agency.
Payees must keep the Government agency informed of any address
changes in order to receive important information about benefits and to
remain qualified for payments.
SECTION 1
(TO BE COMPLETED BY PAYEE)
NAME OF PAYEE
(last, first, middle initial)
A
ADDRESS
(street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
B
CLAIM OR PAYROLL ID NUMBER
C
Prefix Suffix
TYPE OF DEPOSITOR ACCOUNT
D
CHECKING SAVINGS
DEPOSITOR ACCOUNT NUMBER
E
TYPE OF PAYMENT
(Check only one)
F
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(s
pecify)
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
(if applicable)
G
TYPE AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
I certify that I am entitled to the payment identified above, and that I have
read and understood the back of this form. In signing this form, I
authorize my payment to be sent to the financial institution named below
to be deposited to the designated account.
JOINT ACCOUNT HOLDERS’ CERTIFICATION
(optional)
I certify that I have read and understood the back of this form,
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
SIGNATURE DATE
SIGNATURE DATE
SIGNATURE DATE
SIGNATURE DATE
SECTION 2
(TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS
SECTION 3
(TO BE COMPLETED BY FINANCIAL INSTITUTION)
NAME AND ADDRESS OF FINANCIAL INSTITUTION
ROUTING NUMBER
CHECK
DIGIT
DEPOSITOR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, I
certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and
210.
PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
Financial institutions should refer to the GREEN BOOK for further instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 7540-01-058-0224 FINANCIAL INSTITUTION COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
ENTER Grant Recipient Organization name
Organization Street Address
ENTER 14-Digit Grant ID Number: XX-#####-##-##-X-##
ENTER EIN here
✘
DOL/ETA Grant
Department of Labor
Employment and Training Administration (ETA)
200 Constitution Avenue, NW
Washington, DC 20210
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 agreemen
t 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 bot
h for presentinga false statement or makinga fraudulent claim.
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Rev 1199a DirectDeposit FORM SF-1199 Form and Instructions

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Completed 19 May 2020

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