Fillable SF1199A-1 Standard Form 1199A, Direct Deposit Sign-up Form, June 1987

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SF1199A-1 Standard Form 1199A, Direct Deposit Sign-up Form, June 1987

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The SF1199A-1 Standard Form 1199A, Direct Deposit Sign-up Form, June 1987 form is 3 pages long and contains:

  • 15 signatures
  • 36 check-boxes
  • 123 other fields

Country of origin: US
File type: PDF

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DIRECT DEPOSIT SIGN-UP FORM
OMB No. 1510-0007
DIRECTIONS
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
B NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Prefix
Suffix
D TYPE OF DEPOSITOR ACCOUNT
CHECKING SAVINGS
E DEPOSITOR ACCOUNT NUMBER
F TYPE OF PAYMENT (Check only one)
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
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)
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
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
NSN 7540-01-058-0224
GOVERNMENT AGENCY COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
Standard From 1199A (EG)
(Rev. June 187)
Prescribed by Treasury Department
Treasury Dept. Cir. 1076
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.
Payee must keep the Government agency informed of any address
changes in order to receive important about benefits and to remain
qualified for payments.
SECTION 1 (TO BE COMPLETED BY PAYEE)
(specify)
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.
I certify that I have read and understood the back of this form,
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
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.
Financial institution should refer to the GREEN BOOK for further instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
A NAME OF PAYEE (last, first, middle initial)
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DIRECT DEPOSIT SIGN-UP FORM
OMB No. 1510-0007
DIRECTIONS
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
B NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Prefix
Suffix
D TYPE OF DEPOSITOR ACCOUNT
CHECKING SAVINGS
E DEPOSITOR ACCOUNT NUMBER
F TYPE OF PAYMENT (Check only one)
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
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)
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
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
NSN 7540-01-058-0224
FINANCIAL INSTITUTION COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
Standard From 1199A (EG)
(Rev. June 187)
Prescribed by Treasury Department
Treasury Dept. Cir. 1076
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.
Payee must keep the Government agency informed of any address
changes in order to receive important about benefits and to remain
qualified for payments.
SECTION 1 (TO BE COMPLETED BY PAYEE)
(specify)
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.
I certify that I have read and understood the back of this form,
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
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.
Financial institution should refer to the GREEN BOOK for further instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
A NAME OF PAYEE (last, first, middle initial)
Reset
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signature
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click to sign
signature
click to edit
click to sign
signature
click to edit
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signature
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signature
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DIRECT DEPOSIT SIGN-UP FORM
OMB No. 1510-0007
DIRECTIONS
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
B NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Prefix
Suffix
D TYPE OF DEPOSITOR ACCOUNT
CHECKING SAVINGS
E DEPOSITOR ACCOUNT NUMBER
F TYPE OF PAYMENT (Check only one)
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
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)
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
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
NSN 7540-01-058-0224
PAYEE COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
Standard From 1199A (EG)
(Rev. June 187)
Prescribed by Treasury Department
Treasury Dept. Cir. 1076
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.
Payee must keep the Government agency informed of any address
changes in order to receive important about benefits and to remain
qualified for payments.
SECTION 1 (TO BE COMPLETED BY PAYEE)
(specify)
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.
I certify that I have read and understood the back of this form,
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
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.
Financial institution should refer to the GREEN BOOK for further instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
A NAME OF PAYEE (last, first, middle initial)
Reset
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
BURDEN ESTIMATE STATEMENT
PLEASE READ THIS CAREFULLY
INFORMATION FOUND ON CHECKS
Type of payment is printed to the left of the amount.
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
CANCELLATION
CHANGING RECEIVING FINANCIAL INSTITUTIONS
FALSE STATEMENTS OR FRAUDULENT CLAIMS
A
C
F
United States Treasury
15-51
000
AUSTIN, TEXAS
Check No.
0000 415785
Month Day Year
08 31
84
29-693-775 00
Pay to
the order of
DOLLARS CTS
$
****100 00
28 28
VA COMP
NOT NEGOTIABLE
’:00000518’: 041571926"
A
F
C
SF 1199A (Back)
The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be directed to the Financial Management Services, 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
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 financial institution and/ or its agent. Failure to provide the
requested information may affect the processing of this form and may delay or prevent the receipt of payments through the
Direct Deposit/Electronic Funds Transfer Program.
Most of the information needed to complete boxes A,
C, and F in Section 1 is printed on your government
check:
Be sure that payee's name is written exactly as it appears
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.
Joint account holders should immediately advise both the Government agency and the financial institution of the death
of a beneficiary. funds deposited after the date of death or in eligibility, except for salary payments, are to be returned to
the Government agency. The Government agency will then make a determination regarding survivor rights, calculate
survivor benefits payments, if any, and begin payments.
The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the
Federal agency or by the death or legal incapacity of the recipient. Upon cancellation 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 recipient
a 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 institution. The financial institution cannot cancel the authorization by advice
to the Government agency.
The payee's Director Deposit will continue to be received by selected financial institution until the Government agency
is notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effect this
change, the payee will complete a 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.
Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for
presenting a false statement or making a fraudulent claim.
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SF1199A-1 Standard Form 1199A, Direct Deposit Sign-up Form, June 1987

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Completed 19 May 2020

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