Standard Form 1199A											                              OMB NO. 1510-0007
(Rev. June 1987)
Prescribed by Treasury

SIGN-UP FORM

    DEPOSIT

DIRECT

   Department
Treasury Dept. Cir. 1076

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 a 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 form 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.
SECTION 1 (TO BE COMPLETED BY PAYEE)
A  NAME OF PAYEE (last, first, middle initial)

     	D   TYPE OF DEPOSITORY ACCOUNT    CHECKING  SAVINGS	
	E    DEPOSITOR ACCOUNT NUMBER	
      ADDRESS (street, route, P.O. Box, APO/FPO)
     		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		
		
      CITY                                          STATE                  ZIP CODE
                                                                        	F    TYPE OF PAYMENT (CHECK ONLY ONE)
 Social Security                                          Fed Salary/Mil. Civilian Pay
 Supplemental Security Income                 Mil. Active      
Railroad Retirement                                   Mil. Retire      
 Civil Service Retirement (OPM)                Mil. Survivor      
 VA Compensation or Pension                   Other      
                                                                                                (specify)	
      TELEPHONE NUMBER
           AREA CODE                      		
B   NAME OF PERSON(S) ENTITLED TO PAYMENT
     		
C   CLAIM OR PAYROLL ID NUMBER   	G   THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)	

           Prefix                                                         Suffix       	TYPE
     	AMOUNT
     	
PAYEE/JOINT PAYEE CERTIFICATION	JOINT ACCOUNT HOLDERS’ CRTIFICATION (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 blow 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
	SIGNATURE
	DATE
	
SIGNATURE	DATE	SIGNATURE	DATE

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

     	GOVERNMENT AGENCY ADDRESS

     	

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
NAME AND ADDRESS OF FINANCIAL INSTITUTION

Bank of America
	ROUTING NUMBER	CHECK
DIGIT	
		0	6	3	1	-	0	0	2	7			7		
		
	DEPOSITOR ACCOUNT TITLE
Chief Financial Office of Florida	
FINACIAL INTITUTION CRTIFICATION	
	
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, 209, and 210.	
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.