Transcription of DIRECT DEPOSIT SIGN-UP FORM
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Example: stock market
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.
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 institution receiving the Direct Deposit. To effect this change, the payee will contact the paying agency with updated financial account information.
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