OMB No. 1530-0006

1199-207

Standard Form 1199A

(Rev. April 2021)

Prescribed by Treasury Department

Treasury Dept. Cir. 1076 DIRECT DEPOSIT SIGN-UP FORM

SECTION 1 (TO BE COMPLETED BY PAYEE)

A

B

C

D

E

F

G

NAME OF PAYEE (last, first, middle initial)

NAME OF PERSON(S) ENTITLED TO PAYMENT

CLAIM OR PAYROLL ID NUMBER

SIGNATURE

SIGNATURE

GOVERNMENT AGENCY NAME

NAME AND ADDRESS OF FINANCIAL INSTITUTION

PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE

ROUTING NUMBER

DEPOSITOR ACCOUNT TITLE

CHECK 

DIGIT

GOVERNMENT AGENCY ADDRESS

SIGNATURE

SIGNATURE

DATE

DATE

DATE

DATE

PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION

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.

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

the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

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

CITY STATE ZIP CODE

TELEPHONE NUMBER

AREA CODE

Prefix Suffix

TYPE OF DEPOSITOR ACCOUNT

DEPOSITOR ACCOUNT NUMBER

TYPE OF PAYMENT (Check only one)

TYPE AMOUNT

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

Social Security

Supplemental Security Income

Railroad Retirement

Civil Service Retirement (OPM)

VA Compensation or Pension

Fed. Salary/Mil. Civilian Pay

Mil. Active

Mil. Retire.

Mil. Survivor

Other

(specify)

CHECKING SAVINGS

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

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

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, 208, and 210.

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.

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. 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.
OMB No. 1530-0006

1199-207

Standard Form 1199A

(Rev. April 2021)

Prescribed by Treasury Department

Treasury Dept. Cir. 1076 DIRECT DEPOSIT SIGN-UP FORM

SECTION 1 (TO BE COMPLETED BY PAYEE)

A

B

C

D

E

F

G

NAME OF PAYEE (last, first, middle initial)

NAME OF PERSON(S) ENTITLED TO PAYMENT

CLAIM OR PAYROLL ID NUMBER

SIGNATURE

SIGNATURE

GOVERNMENT AGENCY NAME

NAME AND ADDRESS OF FINANCIAL INSTITUTION

PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE

ROUTING NUMBER

DEPOSITOR ACCOUNT TITLE

CHECK 

DIGIT

GOVERNMENT AGENCY ADDRESS

SIGNATURE

SIGNATURE

DATE

DATE

DATE

DATE

PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION

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.

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

the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

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

CITY STATE ZIP CODE

TELEPHONE NUMBER

AREA CODE

Prefix Suffix

TYPE OF DEPOSITOR ACCOUNT

DEPOSITOR ACCOUNT NUMBER

TYPE OF PAYMENT (Check only one)

TYPE AMOUNT

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

Social Security

Supplemental Security Income

Railroad Retirement

Civil Service Retirement (OPM)

VA Compensation or Pension

Fed. Salary/Mil. Civilian Pay

Mil. Active

Mil. Retire.

Mil. Survivor

Other

(specify)

CHECKING SAVINGS

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

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

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, 208, and 210.

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.

FINANCIAL INSTITUTION 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. 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.
OMB No. 1530-0006

1199-207

Standard Form 1199A

(Rev. April 2021)

Prescribed by Treasury Department

Treasury Dept. Cir. 1076 DIRECT DEPOSIT SIGN-UP FORM

SECTION 1 (TO BE COMPLETED BY PAYEE)

A

B

C

D

E

F

G

NAME OF PAYEE (last, first, middle initial)

NAME OF PERSON(S) ENTITLED TO PAYMENT

CLAIM OR PAYROLL ID NUMBER

SIGNATURE

SIGNATURE

GOVERNMENT AGENCY NAME

NAME AND ADDRESS OF FINANCIAL INSTITUTION

PRINT OR TYPE REPRESENTATIVE’S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE

ROUTING NUMBER

DEPOSITOR ACCOUNT TITLE

CHECK 

DIGIT

GOVERNMENT AGENCY ADDRESS

SIGNATURE

SIGNATURE

DATE

DATE

DATE

DATE

PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS’ CERTIFICATION

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.

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

the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

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

CITY STATE ZIP CODE

TELEPHONE NUMBER

AREA CODE

Prefix Suffix

TYPE OF DEPOSITOR ACCOUNT

DEPOSITOR ACCOUNT NUMBER

TYPE OF PAYMENT (Check only one)

TYPE AMOUNT

THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

Social Security

Supplemental Security Income

Railroad Retirement

Civil Service Retirement (OPM)

VA Compensation or Pension

Fed. Salary/Mil. Civilian Pay

Mil. Active

Mil. Retire.

Mil. Survivor

Other

(specify)

CHECKING SAVINGS

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

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)

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, 208, and 210.

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.

PAYEE 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. 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.
A

C

F

SF 1199A (Back)

The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper, 

depending on individual circums tances. Comments concerning the accuracy of this burden esimates and suggestions for 

reducing this burden should be directed to the Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 

26106-1328.

 Most of the information needed to complete boxes 

A, C, and F in Section 1 is printed on your government 

check:

 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.

 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.

 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 contact the paying agency with updated financial account information. It is recommended that the 

payee maintain accounts at both financial institutions until the transaction is complete, i.e. after the new financial institution 

receives the payee’s Direct Deposit payment. 

 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.

Be sure that payee’s name is written exactly as it appears 

on the check. Be sure current address is shown.

15-51

:00000518’: 0415771926”

000

28 28 DOLLARS CTS

08 31 84

00

PHILADELPHIA, PA

Pay to

the order of

Check No.

0000 415785

Month Day Year

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.

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

BURDEN ESTIMATE STATEMENT

PLEASE READ THIS CAREFULLY

 All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 208 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

NOT NEGOTIABLE

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

CANCELLATION

CHANGING RECEIVING FINANCIAL INSTITUTIONS

FALSE STATEMENTS OR FRAUDULENT CLAIMS

A

C

F