Form 1199A PDF Details

The 1199A form, also known as the Direct Deposit Sign-Up Form, serves as a critical conduit for individuals receiving federal payments, facilitating the electronic transfer of funds to the payee's bank account, thereby ensuring a faster and more secure receipt of payments ranging from Social Security benefits to federal salaries. This form requires detailed information from the payee, including their name, address, social security number, the type of account into which the funds should be deposited, and the account number itself. It is structured in three sections, where the first part demands completion by the payee, outlining personal and payment information, the second part is for completion by the government agency, and the third is to be filled out by the financial institution receiving the funds. The completion and accuracy of this form are paramount, as it involves sensitive information and has implications for the timeliness and security of the federal payments being processed. Furthermore, the form contains clauses related to joint account holders, emphasizing the importance of notifying both the government agency and financial institution in the event of a beneficiary's death, outlining procedures for the cancellation of the direct deposit agreement, and detailing consequences for failure to provide correct information or making fraudulent claims. This comprehensive approach underscores the commitment to ensuring a seamless transition of funds while safeguarding the integrity of personal and financial data.

QuestionAnswer
Form NameForm 1199A
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesstandard 1199a rev, form 1199, 1199a pdf, 1199 a

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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) (Rev. August 2012)

Prescribed by Treasury Department

Treasury Dept. Cir. 1076

OMB No. 1510-0007

DIRECT DEPOSIT SIGN-UP FORM

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. The financial institution will verify the information in Sections 1 and 2, and will complete Section 3. The completed form will be returned to the Government agency identified below.

A separate form must be completed for each type of payment to be sent by Direct Deposit.

The claim number and type of payment are printed on Government checks. (See the sample check on the back of this form.) This information is also stated on beneficiary/annuitant award letters and other documents from the Government agency.

Payees must keep the Government agency informed of any address changes in order to receive important information about benefits and to remain qualified for payments.

SECTION 1 (TO BE COMPLETED BY PAYEE)

A NAME OF PAYEE (last, first, middle initial)

 

D TYPE OF DEPOSITOR ACCOUNT

 

 

 

CHECKING

 

 

SAVINGS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E DEPOSITOR ACCOUNT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (street, route, P.O. Box, APO/FPO)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

ZIP CODE

F TYPE OF PAYMENT (Check only one)

 

 

 

 

 

 

 

 

Social Security

Fed. Salary/Mil. Civilian Pay

 

 

 

 

Supplemental Security Income

Mil. Active

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Railroad Retirement

Mil. Retire.

 

 

 

 

 

 

 

 

 

 

AREA CODE

 

 

 

 

 

 

 

 

 

 

 

 

Civil Service Retirement (OPM)

Mil. Survivor

 

 

 

 

 

B NAME OF PERSON(S) ENTITLED TO PAYMENT

 

 

 

 

 

 

 

 

VA Compensation or Pension

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

C CLAIM OR PAYROLL ID NUMBER

 

 

G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

 

 

 

TYPE

 

 

 

AMOUNT

 

 

 

 

Prefix

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYEE/JOINT PAYEE CERTIFICATION

 

JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)

I certify that I am entitled to the payment identified above, and that I have

I certify that I have read and understood the back of this form,

read and understood the back of this form. In signing this form, I

including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

authorize my payment to be sent to the financial institution named below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to be deposited to the designated account.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE

 

DATE

SIGNATURE

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE

 

DATE

SIGNATURE

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)

GOVERNMENT AGENCY NAME

GOVERNMENT AGENCY ADDRESS

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

NAME AND ADDRESS OF FINANCIAL INSTITUTION

 

ROUTING NUMBER

 

 

 

 

 

 

 

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIGIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPOSITOR ACCOUNT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL INSTITUTION CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, I

certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and

210.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINT OR TYPE REPRESENTATIVE’S NAME

SIGNATURE OF REPRESENTATIVE

TELEPHONE NUMBER

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Financial institutions should refer to the GREEN BOOK for further instructions.

 

 

 

 

THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.

 

 

 

 

NSN 7540-01-058-0224

 

GOVERNMENT AGENCY COPY

 

 

 

 

 

 

 

 

 

1199-207

Designed using Perform Pro, WHS/DIOR, Mar 97

SF 1199A (Back)

BURDEN ESTIMATE STATEMENT

The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Financial Management Service, Records Management Branch, Room 135, 3700 East-West Highway, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT TO COLLECT THIS DATA. DO NOT SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.

PRIVACY ACT NOTICE

Collection of the information in this Direct Deposit Sign-Up form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397 (November 22, 1943). Your social security number and the other information requested will allow the federal government to process your direct deposit. Your social security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you from other recipients of federal payments. This information will be disclosed to the Department of the Treasury and its fiscal and financial agents, and other federal agencies, as necessary to process your direct deposit. This information may also be disclosed to a court, congressional committee or another government agency as authorized or required to verify your receipt of federal payments. Although providing the requested information is voluntary, your direct deposit cannot be processed without it.

PLEASE READ THIS CAREFULLY

All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or 210. The information is confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requested information may affect the processing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program.

INFORMATION FOUND ON CHECKS

Most of the information needed to complete boxes A and F in Section 1 is printed on your government check:

ABe sure that payee’s name is written exactly as it appears on the check. Be sure current address is shown.

FType of payment is printed to the left of the amount.

United States Treasury 15000-51

 

 

Check No.

 

 

Month Day Year

KANSAS CITY, MO

 

 

 

 

0000 415785

 

08

31

84

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

28

DOLLARS

CTS

Pay to

 

 

 

 

VA COMP

$****100

00

the order of

JOHN DOE

 

 

 

 

 

 

 

123 BRISTOL STREET

F

 

 

 

 

HAWKINS BRANCH TX 76543

 

 

 

 

 

 

 

 

 

 

A

 

 

 

NOT NEGOTIABLE

 

 

 

 

 

 

 

 

 

’:00000518’: 041571926"

 

 

 

 

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

Joint account holders should immediately advise both the Government agency and the financial institution of the death of a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments, are to be returned to the Government agency. The Government agency will then make a determination regarding survivor rights, calculate survivor benefit payments, if any, and begin payments.

CANCELLATION

The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should notify the receiving financial institutionthat he/she is doing so.

The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient a written notice 30 days in advance of the cancellation date. The recipient must immediately advise the Federal agency if the authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by advice to the Government agency.

CHANGING RECEIVINGFINANCIAL INSTITUTIONS

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. It is recommended that the payee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institution receives the payee’s Direct Deposit payment.

FALSE STATEMENTS OR FRAUDULENT CLAIMS

Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for presenting a false statement or making a fraudulent claim.

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The right way to complete direct deposit sign up part 1

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