SF1199a.pdf

OMB No. 1510-0007

Standard Form 1199A

Prescribed by Treasury Department Treasury Department Cir 1076 Call 1 (800) 333-1795 to sign up by telephone.

DIRECTIONS

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.

PLEASE NOTE: In many cases you can also sign up for Direct Deposit by telephone. Toll-free numbers are listed below:

Social Security Administration Office of Personnel Management

(800) 772-1213

(800) 325-0778 TTY

Railroad Retirement Board (Automated System)

(800) 808-0772

(312) 751-4701 TTY

A. PERSON TO RECEIVE PAYMENT

(888) 767-6738

(800) 878-5707 TDD

Department of Veterans Affairs

(877) 838-2778

(800) 827-1000

(800) 829-4833 TDD

C. BANK OR CREDIT UNION INFORMATION

NAME OF PERSON ENTITLED TO PAYMENT (if different from above)

YOUR NAME (last, first, middle initial)

CITY (or APO/FPO)

YOUR TELEPHONE NUMBER

STATE

YOUR SOCIAL SECURITY NUMBER

D. CERTIFICATION

B. TYPE OF PAYMENT

FOR JOINT ACCOUNT HOLDERS

CIVIL SERVICE RETIREMENT

9-DIGIT ROUTING NUMBER ( see sample check on reverse side)

ACCOUNT NUMBER ( see verse side)

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.

I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS on the back of this form.

TYPE OF ACCOUNT

SIGNATURE DATE

SIGNATURE DATE

CHECKING SAVINGS

SUPPLEMENTAL SECURITY INCOME

SOCIAL SECURITY

VA COMPENSATION OR PENSION

RAILROAD RETIREMENT OTHER (specify)

ZIP CODE

YOUR ADDRESS (street, route, P.O.box, apartment number)

(check only one) re

PLEASE READ THIS CAREFULLY

PRIVACY ACT NOTICE

Your social security number and the other information requested will allow the federal government to make payments to you by Direct Deposit. This collection of information is authorized by Title 31 of the United States Code, Section 3332(g). Also, Executive Order 9397, November 22, 1943, authorizes the use of your social security number. Your social security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you from other recipients of federal payments.

This information will be disclosed to the Department of the Treasury or another disbursing official to process federal payments to you by Direct Deposit. This information may also be disclosed to a court, congressional committee or another government agency as authorized or required by federal law and to your financial institution to verify receipt of your federal payments. Although providing the requested information is voluntary, your Direct Deposit payment may be delayed or Treasury may be unable to send it if you fail to provide the information.

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

If your account is a joint account and receives Direct Deposit benefit payments, you must inform the federal agency and the financial institution of the death of a beneficiary. Payments sent by Direct Deposit after the date of death or ineligibility of a beneficiary (except for salary payments) must be returned to the federal agency. The federal agency will then determine if the survivor is eligible for benefits.

CANCELLATION

Your payment will be sent by Direct Deposit until the federal agency that issues the payments is noti-fied to cancel, such as in the case of death or legal incapacity of the payment recipient.

Your financial institution may cancel your Direct Deposit authorization. Your financial institution is required to give you written notice 30 days in advance of the cancellation date. If this occurs, you must notify the federal agency that the Direct Deposit authorization was cancelled.

BURDEN ESTIMATE STATEMENT

The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the burden should be directed to the Financial Management

Service, Administrative Programs Division, Records and Information Management Program, 3700 East-West

Highway, Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED FOR COMMENTS

AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA.

DO NOT SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.