DIRECT DEPOSIT SIGN-UP FORM
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 finanacial 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)
 A NAME OF PAYEE (last, first, middle initial)  D TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS
  ADDRESS (street, route, P.O. Box, APO/FPO)  E DEPOSITOR ACCOUNT NUMBER
                             
  CITY
STATE
ZIP CODE
 F TYPE OF PAYMENT (Check only one)
Social Security Fed Salar/Mil. Civilian Party
Supplemental Security Income   Mil. Active ______________
Railroad Retirement Mil. Retire _______________
Civil Service Retirement (OPM) Mil. Survivor _____________
VA Compensation Pension Other ___________________
 
(specify)
  TELEPHONE NUMBER

  AREA CODE
 B NAME OF PESON(S) ENTITLED TO PAYMENT
 C CLAIM OR PAYROLL ID NUMBER
           Prefix                                                    Suffix
  G THIS BOX FOR ALLOTMENT OR PAYMENT ONLY (if applicable)
 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' CERTIFICAION (optional)
   I certify that I have read and understood the back of this form, including the SPECIAL NOTE 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
     U.S. Embassy
     1131 Roxas Blvd., Ermita
     Manila, Philippines

SECTION 3 (TO BE COMPLETED BY PAYEE OR 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 REPRESENTATIVES NAME  SIGNATURE OF REPRESENTATIVES  TELEPHONE NUMBER    DATE