Transcription of DIRECT DEPOSIT SIGN-UP FORM
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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 onl)
OMB No. 1530-0006 1199-207 Standard Form 1199A (Rev. April 2021) Prescribed by Treasury Department Treasury Dept. Cir. 1076 DIRECT DEPOSIT SIGN-UP FORM SECTION 1 (TO ...
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