NATIONAL INTERAGENCY FIRE CENTER

CASUAL PAYMENT CENTER

3833 S DEVELOPMENT AVE, BOISE, ID 83705-5354 

EMAIL: CASUALPAY@BLM.GOV

PHONE: 877-471-2262 FAX: 208-433-6405 

 

 

REMOVAL OF DIRECT DEPOSIT FORM/EFT WAIVER REQUEST

Check one: BIA BLM FWS NPS

NAME: SSN: 

................................................................................................................................................................................................... 

Complete this form to remove your Direct Deposit and have your future payments sent as Treasury 

Checks to a Mailing Address. 

Remove my Direct Deposit and send my future payments as Treasury Checks to the following Mailing and 

Correspondence Address: 

ADDRESS: 

 

CITY STATE ZIP 

According to 31 CFR Part 208.4 you may apply for a waiver if either of the following conditions exists (please indicate 

which condition applies to you by checking the appropriate box. You may check more than one):

A) “Electronic funds transfer would impose a hardship because of the individual's inability to manage an account 

at a financial institution due to a mental impairment,” or

B) “Electronic funds transfer would impose a hardship because of the individual's inability to manage an account 

at a financial institution due to the individual living in a remote geographic location lacking the infrastructure to 

support electronic financial transactions.” 

This waiver will remain in effect for the current calendar year only. Payments will be sent by paper check to the current 

mailing address on file. To make changes to your mailing address, complete and send a W-4 or Address Change Form. 

By signing, I attest that I am the person named above and that I have read and understand the information 

presented. I am requesting a waiver to keep my Federal payment from being deposited electronically. I understand 

that all payments will be made by paper check and that in the event the check is lost, stolen, mutilated, or forged it 

may take up to six weeks or more to trace the check.

...................................................................................................................................................................................................

SIGNATURE: DATE: PHONE #: 

Privacy Act Statement: Information on this form is collected under the authority of the Administratively Determined (AD) Pay Plan. Information collected via this form is covered by the Privacy Act of 1974 and Privacy 

Act System of Records Notice DOI-85. The primary use of this information is to start, stop, or change entitlements and to process any voluntary or involuntary deductions on pay and leave issues. The information you 

furnish will be used to identify records properly associated with you, to obtain additional information to update your record, if necessary, and to determine any present or future entitlement. Disclosure may be made 

only to authorized persons according to Title 5 USC 552a and for uses described in System of Records Notices DOI-85. Submission of the information in this form is voluntary; however, requests will not be completed 

without the information needed to process the request. 

Revised 01/2022