STANDARD FORM 1199A OMB No. 1510-0007 
(Rev. 9/83) Expiration Date 1/31/90 

Prescribed by Treasury 

Department 
Treasury Dept. Cir. 1076 

SIGN-UP FORM 

DIRECTIONS 

. To sign up for Direct Deposit, the payee is to read the back of this form and fill in the information . The claim number and type of payment are printed on Government checks. (See the sample check 
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters 
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section and other documents from the Government agency. 

3. The completed form will be returned to the Govern- ment agency identified below. 
Payees must keep the Government agency informed of any address changes in order to receive 
A separate form must be completed for each type of payment to be sent by Direct Deposit . important information about benefits and to remain qualified for payments. 

. 

SECTION 1 (TO BE COMPLETED BY PAYEE) 

NAME OF PAYEE (last, first, middle initial) A 
(text) 
TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGSD 
(: On) Unchecked
(: On) Unchecked
DEPOSITOR ACCOUNT NUMBER E
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
ADDRESS (street, route, P.O. box, APO/FPO) 
(text) 
CITY STATE 
(text) 
ZIP CODE TYPE OF PAYMENT (Check only one) 
Fed Salary/Mil. Civilian Pay 
Mil. Active 
Mil. Retire. 
Mil. Survivor 
Other 
(specify) 
F 
Social Security 
Supplemental Security Income 
Railroad Retirement 
Civil Service Retirement (OPM) 
VA Compensation or Pension 
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(text) 
(text) 
(text) 
(text) 
(checkbox) Unchecked
TELEPHONE NUMBER 
AREA CODE 
B 
(text) 
NAME OF PERSON(S) ENTITLED TO PAYMENT C 
(text) 
CLAIM OR PAYROLL ID NUMBER THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable) G 
Prefix Suffix 
(text) 
(text) 
TYPE 
(text) 
AMOUNT 
(text) 
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS' CERTIFICATION (optional) 
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. 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 


SECTION 2 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS 

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK 
DIGIT 
DEPOSITOR ACCOUNT TITLE 
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 cer- tify that the financial institution agress to receive and deposit the 
payment identified above in accordance with 31 CFR Parts 240, 209, and 210. 
FINANCIAL INSTITUTION CERTIFICATION 
PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE 

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 

NSN 7540-01-058-0224 1199-204 


STANDARD FORM 1199A OMB No. 1510-0007 
(Rev. 9/83) Expiration Date 1/31/90 

Prescribed by Treasury 

Department 
Treasury Dept. Cir. 1076 

SIGN-UP FORM 

DIRECTIONS 

. To sign up for Direct Deposit, the payee is to read the back of this form and fill in the information . The claim number and type of payment are printed on Government checks. (See the sample check 
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters 
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section and other documents from the Government agency. 

3. The completed form will be returned to the Govern- ment agency identified below. 
Payees must keep the Government agency informed of any address changes in order to receive 
A separate form must be completed for each type of payment to be sent by Direct Deposit . important information about benefits and to remain qualified for payments. 

. 

SECTION 1 (TO BE COMPLETED BY PAYEE) 

NAME OF PAYEE (last, first, middle initial) A 
(text) 
TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGSD 
(: On) Unchecked
(: On) Unchecked
DEPOSITOR ACCOUNT NUMBER E
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
ADDRESS (street, route, P.O. box, APO/FPO) 
(text) 
CITY STATE 
(text) 
ZIP CODE TYPE OF PAYMENT (Check only one) 
Fed Salary/Mil. Civilian Pay 
Mil. Active 
Mil. Retire. 
Mil. Survivor 
Other 
(specify) 
F 
Social Security 
Supplemental Security Income 
Railroad Retirement 
Civil Service Retirement (OPM) 
VA Compensation or Pension 
(text) x
(text) x
(text) 
(text) 
(text) 
(text) 
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
TELEPHONE NUMBER 
AREA CODE 
B 
(text) 
NAME OF PERSON(S) ENTITLED TO PAYMENT C 
(text) 
CLAIM OR PAYROLL ID NUMBER THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable) G 
Prefix Suffix 
(text) 
(text) 
TYPE 
(text) 
AMOUNT 
(text) 
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS' CERTIFICATION (optional) 
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. 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 


SECTION 2 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS 

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK 
DIGIT 
DEPOSITOR ACCOUNT TITLE 
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 cer- tify that the financial institution agress to receive and deposit the 
payment identified above in accordance with 31 CFR Parts 240, 209, and 210. 
FINANCIAL INSTITUTION CERTIFICATION 
PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE 

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 

NSN 7540-01-058-0224 1199-204 


STANDARD FORM 1199A OMB No. 1510-0007 
(Rev. 9/83) Expiration Date 1/31/90 

Prescribed by Treasury 

Department 
Treasury Dept. Cir. 1076 

SIGN-UP FORM 

DIRECTIONS 

. To sign up for Direct Deposit, the payee is to read the back of this form and fill in the information . The claim number and type of payment are printed on Government checks. (See the sample check 
requested in Sections 1 and 2. Then take or mail this form to the financial institution. The on the back of this form.) This informa- tion is also stated on beneficiary/annuitant award letters 
financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section and other documents from the Government agency. 

3. The completed form will be returned to the Govern- ment agency identified below. 
Payees must keep the Government agency informed of any address changes in order to receive 
A separate form must be completed for each type of payment to be sent by Direct Deposit . important information about benefits and to remain qualified for payments. 

. 

SECTION 1 (TO BE COMPLETED BY PAYEE) 

NAME OF PAYEE (last, first, middle initial) A 
(text) 
TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGSD 
(: On) Unchecked
(: On) Unchecked
DEPOSITOR ACCOUNT NUMBER E
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
(text) 
ADDRESS (street, route, P.O. box, APO/FPO) 
(text) 
CITY STATE 
(text) 
ZIP CODE TYPE OF PAYMENT (Check only one) 
Fed Salary/Mil. Civilian Pay 
Mil. Active 
Mil. Retire. 
Mil. Survivor 
Other 
(specify) 
F 
Social Security 
Supplemental Security Income 
Railroad Retirement 
Civil Service Retirement (OPM) 
VA Compensation or Pension 
(text) 
(text) 
(text) 
(text) 
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
(: On) Unchecked
TELEPHONE NUMBER 
AREA CODE 
B 
(text) 
NAME OF PERSON(S) ENTITLED TO PAYMENT C 
(text) 
CLAIM OR PAYROLL ID NUMBER THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable) G 
Prefix Suffix 
(text) 
(text) 
TYPE 
(text) 
AMOUNT 
(text) 
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS' CERTIFICATION (optional) 
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. 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 
SIGNATURE DATE 
(text) 


SECTION 2 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS 

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) 


NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK 
DIGIT 
DEPOSITOR ACCOUNT TITLE 
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 cer- tify that the financial institution agress to receive and deposit the 
payment identified above in accordance with 31 CFR Parts 240, 209, and 210. 
FINANCIAL INSTITUTION CERTIFICATION 
PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE 

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(S) COPY 

NSN 7540-01-058-0224 1199-204