Casual Hire Payment Information Direct Deposit

+---------------+----------------------+------------------+-----------+
| **Standard    | ![](media/           | **SIGN-UP FORM** | OMB NO.   |
| Form 1199A**  | image1.wmf){width="2 |                  | 1510-0007 |
|               | .1951388888888888in" |                  |           |
| (Rev. June    | height="0.2          |                  |           |
| 1987)         | 8055555555555556in"} |                  |           |
|               |                      |                  |           |
| Prescribed by |                      |                  |           |
| Treasury      |                      |                  |           |
|               |                      |                  |           |
| Department    |                      |                  |           |
|               |                      |                  |           |
| Treasury      |                      |                  |           |
| Dept. Cir.    |                      |                  |           |
| 1076          |                      |                  |           |
+---------------+----------------------+------------------+-----------+

<table>
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<tbody>
<tr class="odd">
<td colspan="13"><strong>DIRECTIONS</strong></td>
</tr>
<tr class="even">
<td colspan="7"><ul>
<li><p>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 final
institution will verify the information in Sections 1 and 2, and will
complete Section 3. The completed form will be return to the Government
agency identified below.</p></li>
<li><p>A separate form must be completed for each type of payment to be
sent by Direct Deposit.</p></li>
</ul></td>
<td colspan="2"></td>
<td colspan="4"><ul>
<li><p>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.</p></li>
<li><p>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.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>SECTION 1</strong> <em>(TO BE COMPLETED BY
PAYEE)</em></td>
</tr>
<tr class="even">
<td rowspan="2"><strong>A</strong></td>
<td colspan="5">NAME OF PAYEE <em>(last, first, middle
initial)</em></td>
<td colspan="2"><strong>D</strong></td>
<td colspan="5">TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS</td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="2" rowspan="3"><strong>E</strong></td>
<td colspan="5">DEPOSITOR ACCOUNT NUMBER</td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="5">ADDRESS <em>(street, route, P.O. Box, APO/FPO)</em></td>
<td colspan="5" rowspan="2"><table>
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<tbody>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody>
</table></td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="2">CITY</td>
<td>STATE</td>
<td colspan="2">ZIP CODE</td>
<td colspan="2" rowspan="6"><strong>F</strong></td>
<td colspan="5">TYPE OF PAYMENT <em>(Check only one)</em></td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td>  </td>
<td colspan="2">     </td>
<td colspan="2" rowspan="5"><p> Social Security</p>
<p> Supplemental Security Income</p>
<p> Railroad Retirement</p>
<p> Civil Service Retirement (OPM)</p>
<p> VA Compensation or Pension</p></td>
<td colspan="3" rowspan="5"><p> Fed Salary/Mil. Civilian Pay</p>
<p> Mil. Active</p>
<p> Mil. Retire.</p>
<p> Mil. Survivor</p>
<p> Other <strong>Casual Hire</strong></p></td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="5">TELEPHONE NUMBER</td>
</tr>
<tr class="odd">
<td colspan="5">AREA CODE      </td>
</tr>
<tr class="even">
<td rowspan="2"><strong>B</strong></td>
<td colspan="5">NAME OF PERSON(S) ENTITLED TO PAYMENT</td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
</tr>
<tr class="even">
<td rowspan="3"><strong>C</strong></td>
<td colspan="5">CLAIM OR PAYROLL ID NUMBER</td>
<td colspan="2"><strong>G</strong></td>
<td colspan="5">THIS BOX FOR ALLOTMENT OF PAYMENT ONLY <em>(if
applicable)</em></td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="4">     </td>
<td colspan="5">TYPE</td>
<td colspan="2">AMOUNT</td>
</tr>
<tr class="even">
<td>Prefix</td>
<td colspan="4">Suffix</td>
<td colspan="5">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="6"><strong>PAYEE/JOINT PAYEE CERTIFICATION</strong></td>
<td colspan="7"><strong>JOINT ACCOUNT HOLDERS’ CERTIFICATION</strong>
<em>(optional)</em></td>
</tr>
<tr class="even">
<td colspan="6">I 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 account.</td>
<td colspan="7">I certify that I have read and understood the back of
this form, including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.</td>
</tr>
<tr class="odd">
<td colspan="5">SIGNATURE</td>
<td>DATE</td>
<td colspan="6">SIGNATURE</td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td>     </td>
<td colspan="6">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="5">SIGNATURE</td>
<td>DATE</td>
<td colspan="6">SIGNATURE</td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td>     </td>
<td colspan="6">     </td>
<td>     </td>
</tr>
</tbody>
</table>

+---------------------------------+------------------------------------+
| **SECTION 2** *(TO BE COMPLETED |                                    |
| BY PAYEE OR FINANCIAL           |                                    |
| INSTITUTION)*                   |                                    |
+---------------------------------+------------------------------------+
| GOVERNMENT AGENCY NAME          | GOVERNMENT AGENCY ADDRESS          |
+---------------------------------+------------------------------------+
| **USDA Forest Service, ASC**    | **101 B Sun Ave, NE**              |
|                                 |                                    |
| **Incident Finance -- Casual    | **Albuquerque, NM 87109**          |
| Pay**                           |                                    |
+---------------------------------+------------------------------------+

+------------------------+-----------------+-----+---------------+---+
| **SECTION 3** *(TO BE  |                 |     |               |   |
| COMPLETED BY FINANCIAL |                 |     |               |   |
| INSTITUTION)*          |                 |     |               |   |
+------------------------+-----------------+-----+---------------+---+
| NAME AND ADDRESS OF    |                 | R   |               | C |
| FINANCIAL INSTITUTION  |                 | OUT |               | H |
|                        |                 | ING |               | E |
|                        |                 | NUM |               | C |
|                        |                 | BER |               | K |
|                        |                 |     |               |   |
|                        |                 |     |               | D |
|                        |                 |     |               | I |
|                        |                 |     |               | G |
|                        |                 |     |               | I |
|                        |                 |     |               | T |
+------------------------+-----------------+-----+---------------+---+
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+------------------------+-----------------+-----+---------------+---+
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|                        |                 |     |               | - |
|                        |                 |     |               | - |
|                        |                 |     |               | - |
+------------------------+-----------------+-----+---------------+---+
| **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          | SIGNATURE OF    |     | TELEPHONE     | D |
| REPRESENTATIVE'S NAME  | REPRESENTATIVE  |     | NUMBER        | A |
|                        |                 |     |               | T |
|                        |                 |     |               | E |
+------------------------+-----------------+-----+---------------+---+
|                        |                 |     |               |   |
|                        |                 |     |               |   |
|                        |                 |     |               |   |
|                        |                 |     |               |   |
|                        |                 |     |               |   |
+------------------------+-----------------+-----+---------------+---+

  ----------------------------------- -----------------------------------
  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                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 suggestions 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 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,                            ![](media/image2.wmf){width="4.1375in"
  C, and F in Section 1 is printed on your government                            height="1.8791666666666667in"}
  check:                                                                         

  ![](media/image3.wmf){width="0.15347222222222223in"   Be sure that the payee's 
  height="0.15347222222222223in"}                       name is written exactly  
                                                        as it appears on the     
                                                        check. Be sure current   
                                                        address is shown.        

  ![](media/image4.wmf){width="0.15347222222222223in"   Claim numbers and        
  height="0.15347222222222223in"}                       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.       

  ![](media/image5.wmf){width="0.1625in"                Type of payment is       
  height="0.1625in"}                                    printed to the left of   
                                                        the amount.              
  ----------------------------------------------------- ------------------------ -------------------------------------------

**SPECIAL NOTE 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
institution that 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 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 institution
receiving the Direct Deposit. To effect this change, the payee will
complete the new SF 119A 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.