Standart Form 1199A PDF Details

Are you familiar with Standard Form SF-1199A, Direct Deposit Sign-up - Health Insurance Marketplace Physician Statement? This form is a vital part of setting up direct deposit for health insurance premiums and managing a healthcare provider's payments when signing up on the Health Insurance Marketplace. Knowing how to complete this form correctly can help simplify your billing process as well as make sure that your payment is processed in an efficient manner. In this post, we will discuss what SF-1199A is, adoption options available on the marketplace, and tips to successfully completing the sign-up process. So if you're looking for more information about Standard Form 1199A, keep reading!

QuestionAnswer
Form NameStandart Form 1199A
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other names1199 207, 1199 207 fillable form, sf 1199 blank, government form 1199 207

Form Preview Example

Standard Form 1199A

 

 

 

OMB No. 1510-0007

(Rev. June 1987)

 

 

 

 

Prescribed by Treasury

 

 

 

 

Department

 

 

 

SIGN -UP FORM

Treasury Dept. Cir. 1076

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 in- stitution will verify the information in Sections 1 and 2, and will com- plete Section 3. The completed form will be returned to the Govern- ment 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 informa- tion 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 N A M E

OF P A Y E E (last,

first, middle initial)

 

 

 

D TYPE OF DEPOSITOR ACCOUNT

 

 

 

 

C H E C K I N G

 

 

 

S A V I N G S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A D D R E S S (street, route,

P.O. Box, APO/FPO)

 

 

.

EE DEPOSITOR ACCOUNT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C I T Y

 

S T A T E

 

Z I P C O D E

 

F TYPE OF PAYMENT

(Check only one)

 

 

 

 

 

 

 

 

 

 

 

Social Security

 

 

 

Fed Salary/Mil. Civilian

Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income

Mil. Active

 

 

 

 

 

 

 

T E L E P H O N E N U M B E R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A R E A C O D E

 

 

 

 

Railroad Retirement

 

 

 

Mil. Retire.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mil. Survivor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civil Service Retirement

(OPM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B N A M E

O F P E R S O N ( S )

E N T I T L E D T O P A Y M E N T

 

VA Compensation or Pension

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C C L A I M

O R P A Y R O L L

I D N U M B E R

 

 

 

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

 

 

 

 

 

 

T Y P E

 

 

 

 

 

 

 

 

A M O U N T

 

 

 

 

 

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

 

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

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

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

G O V E R N M E N T A G E N C Y N A M E

GOVERNMENT AGENCY ADDRESS

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

NAME AND ADDRESS OF F I N A N C I AL INSTITUTION

 

 

R O U T I N G N U M B E R

 

 

 

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIGIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D E P O S I T O R A C C O U N T T I T L E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 financialinstitution, I cer- tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31CFR Parts 240, 209, and 210.

PRINT OR TYPE REPRESENTATIVE’S NAME

SIGNATURE OF REPRESENTATIVE

T E L E P H O N E N U M B E R

D A T E

 

 

 

 

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

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

N SN 7 5 4 0 - 0 1 - 0 5 8 - 0 2 2 4

GOVERNM ENT AGENCY COPY

1199-207

 

BURDEN ESTIMATE STATEMENT

The estimated average burden associated with this collection of information is 10 minutes per respondent or record- keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and sug- gestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property & Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget, Paperwork Reduction Project (1510-0007),Washington, D.C. 20503.

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 finan- cial institution and/or its agent. Failure to provide the requested information may affect the process- ing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Elec- tronic Funds Transfer Program.

INFORMATION FOUND ON CHECKS

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

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

C Claim numbers. and suffixes are printed here on checks beneath the date for the type of payment shown here. Check the Green Book for the location of prefixes and suffixes for other types of payments.

,

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

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

Joint account holders should immediately advise both the Government age c and the finan- cial 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 reci- pient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancella- tion by the recipient, the recipient should notify the receiving financial institution that he/she is doing so.

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

CHANGING RECEIVING FINANCIAL 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 in- stitution 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 l 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.

Standard Form 1199A

 

 

 

OMB No. 1510-0007

(Rev. June 1987)

 

 

 

 

Prescribed by Treasury

 

 

 

 

Department

 

 

 

SIGN -UP FORM

Treasury Dept. Cir. 1076

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 in- stitution will verify the information in Sections 1 and 2, and will com- plete Section 3. The completed form will be returned to the Govern- ment 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 informa- tion 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 N A M E

O F P A Y E E (last,

first, middle initial)

 

 

 

D TYPE OF DEPOSITOR ACCOUNT

 

 

 

 

C H E C K I N G

 

 

 

S A V I N G S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A D D R E S S (street, route,

P.O. Box, APO/FPO)

 

 

.

EE DEPOSITOR ACCOUNT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C I T Y

 

S T A T E

 

Z I P C O D E

 

F TYPE OF PAYMENT

(Check only one)

 

 

 

 

 

 

 

 

 

 

 

Social Security

 

 

 

Fed Salary/Mil. Civilian

Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income

Mil. Active

 

 

 

 

 

 

 

T E L E P H O N E N U M B E R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A R E A C O D E

 

 

 

 

Railroad Retirement

 

 

 

Mil. Retire.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mil. Survivor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civil Service Retirement

(OPM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B N A M E

O F P E R S O N ( S )

E N T I T L E D T O P A Y M E N T

 

VA Compensation or Pension

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C C L A I M

O R P A Y R O L L

I D N U M B E R

 

 

 

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

 

 

 

 

 

 

T Y P E

 

 

 

 

 

 

 

 

A M O U N T

 

 

 

 

 

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

 

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

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

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

G O V E R N M E N T A G E N C Y N A M E

GOVERNMENT AGENCY ADDRESS

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

NAME AND ADDRESS OF F I N A N C I AL INSTITUTION

 

 

R O U T I N G N U M B E R

 

 

 

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIGIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D E P O S I T O R A C C O U N T T I T L E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 financialinstitution, I cer- tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31CFR Parts 240, 209, and 210.

PRINT OR TYPE REPRESENTATIVE’S NAME

SIGNATURE OF REPRESENTATIVE

T E L E P H O N E N U M B E R

D A T E

 

 

 

 

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

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

N SN 7 5 4 0 - 0 1 - 0 5 8 - 0 2 2 4

FINANCIAL INSTITUTION COPY

1199-207

 

BURDEN ESTIMATE STATEMENT

The estimated average burden associated with this collection of information is 10 minutes per respondent or record- keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and sug- gestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property & Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget, Paperwork Reduction Project (1510-0007),Washington, D.C. 20503.

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 finan- cial institution and/or its agent. Failure to provide the requested information may affect the process- ing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Elec- tronic Funds Transfer Program.

INFORMATION FOUND ON CHECKS

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

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

C Claim numbers. and suffixes are printed here on checks beneath the date for the type of payment shown here. Check the Green Book for the location of prefixes and suffixes for other types of payments.

,

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

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

Joint account holders should immediately advise both the Government age c and the finan- cial 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 reci- pient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancella- tion by the recipient, the recipient should notify the receiving financial institution that he/she is doing so.

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

CHANGING RECEIVING FINANCIAL 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 in- stitution 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 l 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.

Standard Form 1199A

 

 

 

OMB No. 1510-0007

(Rev. June 1987)

 

 

 

 

Prescribed by Treasury

 

 

 

 

Department

 

 

 

SIGN -UP FORM

Treasury Dept. Cir. 1076

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 in- stitution will verify the information in Sections 1 and 2, and will com- plete Section 3. The completed form will be returned to the Govern- ment 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 informa- tion 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 N A M E

O F P A Y E E (last,

first, middle initial)

 

 

 

D TYPE OF DEPOSITOR ACCOUNT

 

 

 

 

C H E C K I N G

 

 

 

S A V I N G S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A D D R E S S (street, route,

P.O. Box, APO/FPO)

 

 

.

EE DEPOSITOR ACCOUNT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C I T Y

 

S T A T E

 

Z I P C O D E

 

F TYPE OF PAYMENT

(Check only one)

 

 

 

 

 

 

 

 

 

 

 

Social Security

 

 

 

Fed Salary/Mil. Civilian

Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income

Mil. Active

 

 

 

 

 

 

 

T E L E P H O N E N U M B E R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A R E A C O D E

 

 

 

 

Railroad Retirement

 

 

 

Mil. Retire.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mil. Survivor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civil Service Retirement

(OPM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B N A M E

O F P E R S O N ( S )

E N T I T L E D T O P A Y M E N T

 

VA Compensation or Pension

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C C L A I M

O R P A Y R O L L

I D N U M B E R

 

 

 

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

 

 

 

 

 

 

T Y P E

 

 

 

 

 

 

 

 

A M O U N T

 

 

 

 

 

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

 

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

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

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S I G N A T U R E

 

 

D A T E

 

S I G N A T U R E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D A T E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

G O V E R N M E N T A G E N C Y N A M E

GOVERNMENT AGENCY ADDRESS

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

NAME AND ADDRESS OF F I N A N C I AL INSTITUTION

 

 

R O U T I N G N U M B E R

 

 

 

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIGIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D E P O S I T O R A C C O U N T T I T L E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 financialinstitution, I cer- tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31CFR Parts 240, 209, and 210.

PRINT OR TYPE REPRESENTATIVE’S NAME

SIGNATURE OF REPRESENTATIVE

T E L E P H O N E N U M B E R

D A T E

 

 

 

 

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

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

N SN 7 5 4 0 - 0 1 - 0 5 8 - 0 2 2 4

PAYEE(S) COPY

1199-207

 

BURDEN ESTIMATE STATEMENT

The estimated average burden associated with this collection of information is 10 minutes per respondent or record- keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and sug- gestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property & Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget, Paperwork Reduction Project (1510-0007),Washington, D.C. 20503.

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 finan- cial institution and/or its agent. Failure to provide the requested information may affect the process- ing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Elec- tronic Funds Transfer Program.

INFORMATION FOUND ON CHECKS

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

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

C Claim numbers. and suffixes are printed here on checks beneath the date for the type of payment shown here. Check the Green Book for the location of prefixes and suffixes for other types of payments.

,

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

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

Joint account holders should immediately advise both the Government age c and the finan- cial 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 reci- pient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancella- tion by the recipient, the recipient should notify the receiving financial institution that he/she is doing so.

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

CHANGING RECEIVING FINANCIAL 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 in- stitution 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 l 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.

How to Edit Standart Form 1199A Online for Free

With the help of the online PDF tool by FormsPal, you're able to fill in or modify direct deposit form 1199 207 here and now. Our editor is continually evolving to provide the very best user experience attainable, and that's thanks to our resolve for continuous improvement and listening closely to comments from customers. It just takes just a few basic steps:

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This PDF will require specific details to be filled out, hence ensure that you take whatever time to provide precisely what is required:

1. It's essential to complete the direct deposit form 1199 207 correctly, so be attentive when filling out the areas containing all of these blanks:

How to fill in government form 1199 207 step 1

2. When this section is done, you're ready to add the necessary particulars in N A M E A N D A D D R E S S O F, F I N A N C I A L I N S T I T U T, R O U T I N G N U M B E R, C H E C K D I G I T, D E P O S I T O R A C C O U N T T, FINANCIAL INSTITUTION CERTIFICATION, I confirm the identity of the, P R I N T O R T Y P E R E P R E S, S I G N A T U R E O F R E P R E S, T E L E P H O N E N U M B E R, D A T E, Financial institutions should, THE FINANCIAL INSTITUTION, SHOULD MAIL THE COMPLETED FORM TO, and N SN so you can move forward to the 3rd step.

How you can complete government form 1199 207 part 2

Always be very careful when completing T E L E P H O N E N U M B E R and F I N A N C I A L I N S T I T U T, because this is where many people make some mistakes.

3. This next segment is pretty simple, SECTION TO BE COMPLETED BY PAYEE, A N A M E O F P A Y E E last first, T Y P E O F D E P O S I T O R A C, C H E C K I N G, S A V I N G S, A D D R E S S street route PO Box, E DEPOSITOR ACCOUNT NUMBER, C I T Y, S T A T E, Z I P C O D E, TYPE OF PAYMENT Check only one, T E L E P H O N E N U M B E R, A R E A C O D E, B N A M E O F P E R S O N S E N, and C C L A I M O R P A Y R O L L I D - all these empty fields has to be filled out here.

B N A M E O F P E R S O N S E N, A N A M E O F P A Y E E last first, and E DEPOSITOR ACCOUNT NUMBER in government form 1199 207

4. Your next part requires your details in the subsequent areas: N A M E A N D A D D R E S S O F, F I N A N C I A L I N S T I T U T, R O U T I N G N U M B E R, C H E C K D I G I T, D E P O S I T O R A C C O U N T T, FINANCIAL INSTITUTION CERTIFICATION, I confirm the identity of the, P R I N T O R T Y P E R E P R E S, S I G N A T U R E O F R E P R E S, T E L E P H O N E N U M B E R, D A T E, Financial institutions should, THE FINANCIAL INSTITUTION, SHOULD MAIL THE COMPLETED FORM TO, and N SN. Make sure you provide all of the needed details to move forward.

R O U T I N G N U M B E R, N SN, and D E P O S I T O R A C C O U N T T in government form 1199 207

5. The last stage to complete this form is crucial. Be sure to fill in the displayed fields, which includes SECTION TO BE COMPLETED BY PAYEE, A N A M E O F P A Y E E last first, T Y P E O F D E P O S I T O R A C, C H E C K I N G, S A V I N G S, A D D R E S S street route PO Box, E DEPOSITOR ACCOUNT NUMBER, C I T Y, S T A T E, Z I P C O D E, TYPE OF PAYMENT Check only one, T E L E P H O N E N U M B E R, A R E A C O D E, B N A M E O F P E R S O N S E N, and C C L A I M O R P A Y R O L L I D, prior to using the document. Failing to do so can result in an unfinished and potentially nonvalid document!

Part number 5 of completing government form 1199 207

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