DIRECT DEPOSIT SIGN-UP FORM

OMB No. 1530-00061199-207 Standard Form 1199A(Rev. April 2021)Prescribed by Treasury Department Treasury Dept. Cir. 1076 DIRECT DEPOSIT SIGN-UP FORMSECTION 1 (TO BE COMPLETED BY PAYEE)ABCDEFGNAME OF PAYEE (last, first, middle initial)NAME OF PERSON(S) ENTITLED TO PAYMENTCLAIM OR PAYROLL ID NUMBERSIGNATURESIGNATUREGOVERNMENT AGENCY NAMENAME AND ADDRESS OF FINANCIAL INSTITUTIONPRINT OR TYPE REPRESENTATIVE S NAMESIGNATURE OF REPRESENTATIVETELEPHONE NUMBERDATEROUTING NUMBERDEPOSITOR ACCOUNT TITLECHECK DIGITGOVERNMENT AGENCY ADDRESSSIGNATURESIGNATUREDATEDATEDATEDAT EPAYEE/JOINT PAYEE CERTIFICATIONJOINT ACCOUNT HOLDERS CERTIFICATIONI 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 certify that I have read and understood the back of this form, including the SPECIAL NOTICE TO JOINT ACCOUNT (street, route, Box, APO/FPO)CITYSTATEZIP CODETELEPHONE NUMBERAREA CODEP refix SuffixTYPE OF DEPOSITOR ACCOUNTDEPOSITOR ACCOUNT NUMBERTYPE OF PAYMENT (Check only one)TYPEAMOUNTTHIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)Social SecuritySupplemental Security IncomeRailroa

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 …

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