Transcription of DIRECT DEPOSIT SIGN-UP FORM
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Example: bachelor of science
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 FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE. GOVERNMENT AGENCY COPY DIRECTIONS 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.
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