Maryland Direct Deposit Form 3 - Free Download
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Maryland Direct Deposit Form 3
Maryland Direct Deposit Form 3
Standard Form 1199A (EG)
(Rev. August 2012)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
OMB No. 1510-0007
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 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 from 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)
NAME OF PAYEE
(last, first, middle initial)
A
ADDRESS
(street, route, P.O. Box, APO/FPO)
CITY STATE ZIP CODE
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
B
CLAIM OR PAYROLL ID NUMBER
C
Prefix Suffix
TYPE OF DEPOSITOR ACCOUNT
D
CHECKING SAVINGS
DEPOSITOR ACCOUNT NUMBER
E
TYPE OF PAYMENT
(Check only one)
F
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(s
pecify)
THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
(if applicable)
G
TYPE AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
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.
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.
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
ROUTING NUMBER
CHECK
DIGIT
DEPOSITOR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
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.
NSN 7540-01-058-0224 GOVERNMENT AGENCY COPY
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
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