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S4ar~d~rd F®rer~ 11~9A OMB No. 1510-0007 <br /> . ~ (Rev. June 1967) _ <br /> Prescribed by Treasurq <br /> ' ~ Department -_g t ~ <br /> Treasury Dept. Cir. 9076 ~ ~ ~ I o ~ ® <br /> ®IRECTIONS <br /> ® To sign up for Direct Deposit, the payee is Yo read the back of this The claim number and type of payment are printed on Government <br /> form and fill in the information requested in Sections 1 and 2. Then checks. (See the Sample check on the back of this form.) This inform~- <br /> take or mail Phis form 4o the financial institution. The financial in- Lion is also stated on beneficiary/annuitan4,award letters and other <br /> stitution will verify the information in Sections 1 and 2, and will com- documents from the Government agency. <br /> plete Section 3. The completed form will be returned to 4he Govern- <br /> men4 agency identified below. ® Payees mus4 keep the Governmen4 agency informed of any address <br /> changes in order 4o receive important information abou4 benefits and <br /> ® A separate form must be completed for each Yype of paymen4 Yo be 4o remain qualified for payments. <br /> ~ sent by Direct Deposit. <br /> SECI'I®N 1 (TO BE COMPLETED BY PAYEE) <br /> ~ NAME OF PAY E (last, first, middle initial) <br /> ® TYPE OF DEPOSITOR ACCOUNT CHECKING ?SAVINGS <br /> AD RESS11,S,treet, route, P O. BOX, APO~FPOJ ~ DEPOSITOR ACCOUNT NUMBER <br /> CITY STATE ZIP CODE F TYPE OF PAYMENT (Check only one) <br /> f Q(~.~? 1.8 ~ q ~ ? Social Security ? Fed Salary/Mil.- Civilian Pay <br /> TELEP ONE NUM ER f, ~7//~~ ?Supplemental Security Income ? Mil. Active <br /> AREA CODE ~L.~.~ X~- f~~X~ ? Railroad Retirement ? Mil. Retire. <br /> I CCC~~~ .J v ? Civil Service Retirement (OPM) ? Mil. Survi ~r _ <br /> ~AME OF PERSON(S) E TITLED TO PAYMENT ? VA Compensation or Pension Other ~ <br /> c,,, , 1°,' ~specifYJ <br /> ~ CLAIM OR PAYRO LID UMBER Ca THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (ifapplicableJ <br /> TYPE AMOUNT <br /> ( ~ Prefix ~ Suffix <br /> PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT IiOLDERS' CERTIFICATION (optional) <br /> ~ I certify tha4 I am entitled to the paymen4 identified above, and that I I certify Yha4 I have read and understood the back of Phis form, including <br /> have read and understood 4he back of Phis form. In signing Phis form, I 4he SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS. <br /> authorize my payment to be sent to the financial institution named <br /> below to be deposited. to the designated account. <br /> SIGNATURE DATE SIGNATURE DATE <br /> SIGNATURE DATE SIGNATURE DATE <br /> i <br /> SECT-I®N 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTlTUT10N) <br /> GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS <br /> ~3 'fib®o?l~~ <br /> ~~i~ ~ ~ ~~C~~C t~ <br /> ~ ~ ~ 7~- <br /> 3 SECTI®IV 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) <br /> NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK <br /> e., ~ DIGIT <br /> _i ("y,~ (~"'/~~L.~ DEPOSITOR ACCOUNT TITLE <br /> i <br /> FINANCIAL INSTITUTION CERTIFICATION <br /> I confirm the identity of 4he above-named payee(s) and the account number and title. As representative of the above-named financial institution, I cer- <br /> <br /> € tify tha4 the financial institution agrees to receive and deposit the- payment identified above in accordance with 31 CFR Parts 240, 209, and 210. <br /> <br /> E PRINT OR TYPE REPRESENTATIVE'S NAME SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE <br /> <br /> i <br /> Financial institutions should refer to the GREEN BOOK for further instructions. <br /> THE FINANCIAL INSTITUTION SIiOULD MAIL THE COMPLETED FORM TO TFIE GOVERNMENT AGENCY IDENTIFIED AI30VE. <br /> NsN 7sao-ot-oss-ozza 1199-207 <br /> PflIMED ON PECYGIFD PAPEF <br /> <br />