INSTRUCTIONS for 1199A Form - DOL

INSTRUCTIONS for 1199A Form Section 1 (To be completed by payee ) A. Type or print your name, address and telephone number. B. Type or print your name. C. Type or print your 9-digit social security number. D. Check the type of account you want your funds deposited into. E. Type or print the account number you want your funds deposited into F. (Completed by Agency) G. Leave Blank Sign and date the form. Section 2 (Completed by Agency) Section 3 (To be completed by your financial institution) Standard Form 1199A (EG) OMB No. 1510-0007 (Rev. August 2012) Prescribed by Treasury Department DIRECT DEPOSIT SIGN-UP FORM Treasury Dept. Cir. 1076 DIRECTIONS To sign up for Direct Deposit, the payee is to read the back of this form The claim number and type of payment are printed on Government and fill in the information requested in Sections 1 and 2.

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 complete a new SF 1199A at the newly selected financial institution.

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