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St~Pt!$~u~ F®rr~~ b~'?~A OMB No. 1510-0007 <br /> {Rev. June 1987) <br /> Prescribed by Yreasun,~ <br /> Department - <br /> Treasury Dept. Cir. 1076 ~ ~ ~ w ~ ~ <br /> 1 <br /> DIRECTIONS <br /> ® Ta sign up for Direct Deposit, the payee is Yo read 4he back of this ~ The claim number and type of paymen4 are printed on Government <br /> form and fill in 4he information requested in Sections 1 and 2. Then checks. (See the sample check on the back of Yhis form.) This informa• <br /> II take or mail this form to the financial institution. The financial in- Yion is also stated on benefiicia /annuitant award letters and other <br /> ry <br /> stitution will verify the information in Sections 1 and 2, and will com- documents from the Governmen4 agency. <br /> plete Section 3. The completed form will be returned 4o the Govern- <br /> ment agency identified below. a Payees must keep the Government agency informed of any address <br /> changes in order 4o receive important information about benefits and <br /> ® A separate form must be completed for each type of payment to be to remain qualified for payments. <br /> I sent by Direct Deposit. <br /> <br /> j SECTION 1 (TO BE COMPLETED BY PAYEE) <br /> q NAME OF PAY E (last, first, middle initial) <br /> D TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS <br /> ' ~ ~ ~ ~ ~u E DEPOSITOR ACCOUNT NUMBER IYK <br /> AD RESS streUet~route~l._Box, APO/FPOJ <br /> <br /> ~ STATE 21P CODE <br /> <br /> i <br /> F TYPE OF PAYMENT (Check only one) <br /> ~N~i ~ ~ ~'p ? Sacial Security ? Fed Salary/Mil: Civilian Pay <br /> TELEP ONE NUM ER ?Supplemental Security Income ? Mil. Active <br /> AREA CODE ~1..~-' 1~~CJR ? Railroad Retirement ? Mil. Retire. <br /> CC~~ ? Civil Service Retirement (OPM) ? Mil. Surviypr <br /> ~AME OF PERSON(S) E TITLED TO PAYMENT L <br /> B ~ ? VA Compensatioh or Pension Other <br /> (specify) <br /> C CLAIM OR PAYRO LID UMBER G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (ifapplicableJ <br /> TYPE AMOUNT <br /> Prefix ~ ~ Suffix <br /> PAYEEIJOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS' CERTIFICATION (optiona0 <br /> I certify that I am entitled to the payment identified above, and that I i certify that I have read and understood the back of this form, including <br /> have read and understood the back of Yhis form. In signing this form, I the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS. <br /> authorize my paymen4 to be sent to the financial institution named <br /> below to be deposited to the designated account. <br /> SIGNATURE GATE SIGNATURE DATE <br /> SIGNATURE DATE SIGNATURE DATE <br /> SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION) <br /> GOVERNMENT AGENCY NAME /'~3 ~ J_ h~ ij ~ ~T GOVERNMENT AGENCY ADDRESS <br /> t- ~ ~2 7~ <br /> SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) <br /> NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK <br /> i.J(.Xi D I G I T <br /> ~ aaa D ®aoa a <br /> PQ~~ ~D ~~~aLL D~IEPOSITORL/A~CCcOUNTt~T~~I)TLE ` [,/~n~~ ~~J~- <br /> Lr ~~~FFF / / ~ ~I G. ~~G.B`4~ r' ~ GCl1I~ /-?t..I~L~M <br /> FINANCIAL INSTITUTION CERTIFICATION <br /> 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- <br /> tify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and 210. <br /> PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE <br /> Financial institutions should refer to the GREEN BOOK for further instructions. <br /> THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE. <br /> nlsly 7sao-ot-osa-ozz.z 1199-207 <br /> <br />