___________ _______________

of person entitled to payment)

NAME OF PERSON ENTITLED TO PAYMENT (last, first, middle initial)

YOUR NAME (if different from above)

YOUR ADDRESS (street, route, P.O. box, apartment number)

CITY (or APO/FPO) STATE ZIP CODE

YOUR TELEPHONE NUMBER

( ) -

SOCIAL SECURITY NUMBER OR CLAIM NUMBER (of person entitled to payment)

DIRECT DEPOSIT

OMB No. 1510-0007

Sign-Up Form Standard Form 1199A

(Rev. Feb. 2005) 

Prescribed by Treasury Department 

Treasury Department Cir. 1076

A. PERSON TO RECEIVE PAYMENT C. BANK OR CREDIT UNION INFORMATION

TYPE OF ACCOUNT CHECKING SAVINGS

9-DIGIT ROUTING NUMBER (see sample check on reverse side)

ACCOUNT NUMBER (see reverse side)

D. CERTIFICATION

B. TYPE OF PAYMENT

(check only one)

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

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

payment to be sent to the financial institution named in Part C above, to be 

deposited into the account above.

SIGNATURE DATE

SOCIAL SECURITY

SUPPLEMENTAL SECURITY INCOME 

RAILROAD RETIREMENT

CIVIL SERVICE RETIREMENT

VA COMPENSATION OR PENSION 

OTHER (specify) Casual Pay

FOR JOINT ACCOUNT HOLDERS

I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT 

HOLDERS on the back of this form.

SIGNATURE DATE

DIRECTIONS

Please refer to the information on the reverse side before completing this form.

You must complete a separate form for each type of federal payment (social security, supplemental 

security income, veterans' benefits, etc.).

You are responsible for keeping the paying agency informed of any name or address changes. Return

the completed form to the federal agency from which you will be receiving Direct Deposit payments.

National Interagency Fire Center 

Casual Payment Center 

A Service First Organization 

CASUAL PAYMENT CENTER MS 270

3833 S DEVELOPMENT AVE BOISE, ID 83705-5354

PHONE: 877-471-2262 FAX 208-433-6405
PLEASE READ THIS CAREFULLY

PRIVACY ACT NOTICE

Your social security number and the other information requested will allow the federal government to make 

payments to you by Direct Deposit. This collection of information is authorized by Title 31 of the United States 

Code, Section 3332(g). Also, Executive Order 9397, November 22, 1943, authorizes the use of your social

security number. 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 or another disbursing official to process 

federal payments to you by Direct Deposit. This information may also be disclosed to a court, congressional 

committee or another government agency as authorized or required by federal law and to your financial

institution to verify receipt of your federal payments. Although providing the requested information is

voluntary, your Direct Deposit payment may be delayed or Treasury may be unable to send it if you fail to 

provide the information.

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

If your account is a joint account and receives Direct Deposit benefit payments, you must inform the federal 

agency and the financial institution of the death of a beneficiary. Payments sent by Direct Deposit after the 

date of death or ineligibility of a beneficiary (except for salary payments) must be returned to the federal

agency. The federal agency will then determine if the survivor is eligible for benefits.

CANCELLATION

Your payment will be sent by Direct Deposit until the federal agency that issues the payments is notified to 

cancel,

suchasinthecaseofdeathorlegalincapacityofthepaymentrecipient.

Your financial institution may cancel your Direct Deposit authorization. Your financial institution is required to

give you written notice 30 days in advance of the cancellation date. If this occurs, you must notify the federal 

agency that the Direct Deposit authorization was cancelled.

BURDEN ESTIMATE STATEMENT

The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper, 

depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the 

burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information

Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED

FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT 

SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.