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Form Name:   USAA_Direct_Deposit_Form
Tags:   bank, usaa
Posted By:  
Date:   3/3/2010
Size:   45KB
Type:   .PDF
     
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Standard Form 1199A (EG)(Rev. June 1987)Prescribed by Treasury DepartmentTreasury Dept. Cir. 1076DIRECT DEPOSIT SIGN-UP FORMOMB No. 1510-0007DIRECTIONSTo sign up for Direct Deposit, the payee is to read the back of this formand fill in the information requested in Sections 1 and 2. Then take ormail this form to the financial institution. The financial institution willverify the information in Sections 1 and 2, and will complete Section 3. The completed form will be returned to the Government agencyidentified below.A separate form must be completed for each type of payment to besent by Direct Deposit.The claim number and type of payment are printed on Governmentchecks. (See the sample check on the back of this form.) Thisinformation is also stated on beneficiary/annuitant award letters andother documents from the Government agency.Payees must keep the Government agency informed of any addresschanges in order to receive important information about benefits and toremain qualified for payments.SECTION 1 (TO BE COMPLETED BY PAYEE)NAME OF PAYEE (last, first, middle initial)AADDRESS (street, route, P.O. Box, APO/FPO)CITYSTATEZIP CODETELEPHONE NUMBER AREA CODE NAME OF PERSON(S) ENTITLED TO PAYMENTBCLAIM OR PAYROLL ID NUMBERC Prefix Suffix TYPE OF DEPOSITOR ACCOUNTDCHECKING SAVINGSDEPOSITOR ACCOUNT NUMBERETYPE OF PAYMENT (Check only one)FSocial SecuritySupplemental Security IncomeRailroad RetirementCivil Service Retirement (OPM)VA Compensation or PensionFed. Salary/Mil. Civilian PayMil. ActiveMil. Retire.Mil. SurvivorOther(specify)THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)GTYPEAMOUNTPAYEE/JOINT PAYEE CERTIFICATIONI certify that I am entitled to the payment identified above, and that I haveread and understood the back of this form. In signing this form, Iauthorize my payment to be sent to the financial institution named belowto be deposited to the designated account.JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)I certify that I have read and understood the back of this form,including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.SIGNATUREDATESIGNATUREDATESIGNATUREDATESIGNATUREDATESECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)GOVERNMENT AGENCY NAMEGOVERNMENT AGENCY ADDRESSSECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)NAME AND ADDRESS OF FINANCIAL INSTITUTIONROUTING NUMBERCHECKDIGITDEPOSITOR ACCOUNT TITLEFINANCIAL INSTITUTION CERTIFICATIONI confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, Icertify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and210.PRINT OR TYPE REPRESENTATIVE'S NAMESIGNATURE OF REPRESENTATIVETELEPHONE NUMBERDATEFinancial 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 7540-01-058-0224GOVERNMENT AGENCY COPY1199-207Designed using Perform Pro, WHS/DIOR, Mar 97BURDEN ESTIMATE STATEMENTThe estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper,depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions forreducing 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/or210. The information is confidential and is needed to prove entitlement to payments. The information will be used toprocess payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requestedinformation may affect the processing of this form and may delay or prevent the receipt of payments through the DirectDeposit/Electronic Funds Transfer Program.INFORMATION FOUND ON CHECKS Most of the information needed to complete boxes A,C, and F in Section 1 is printed on your governmentcheck:Be sure that payee's name is written exactly as it ap-pears on the check. Be sure current address is shown.Claim numbers and suffixes are printed here on checksbeneath the date for the type of payment shown here.Check the Green Book for the location of prefixes andsuffixes for other types of payments.Type of payment is printed to the left of the amount.SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS Joint account holders should immediately advise both the Government agency and the financial institution of the deathof a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments, are to be returned tothe Government agency. The Government agency will then make a determination regarding survivor rights, calculatesurvivor 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 theFederal agency or by the death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient shouldnotify 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 recipienta written notice 30 days in advance of the cancellation date. The recipient must immediately advise the Federal agency ifthe authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by adviceto 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 agencyis notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effect thischange, the payee will complete a new SF 1199A at the newly selected financial institution. It is recommended that thepayee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institutionreceives 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 forpresenting a false statement or making a fraudulent claim.ACFUnited States Treasury15-51000AUSTIN, TEXASCheck No.0000 415785Month Day Year 08318429-693-775 00Pay tothe order ofJOHN DOE123 BRISTOL STREETHAWKINS BRANCH TX 76543DOLLARS CTS $****10000 28 28VA COMPNOT NEGOTIABLE':00000518': 041571926"CAFSF 1199A (Back)