PLEASE READ THIS CAREFULLY
All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or 210. The information is confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to the finanacial institution and/or its agent. Failure to provide the requested information may affect the processing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program.
INFORMATION FOUND ON CHECKS
Most of the information needed to complete boxes A,C, and F in Section 1 is printed on your government check:
A Be sure that payee's name is written nexactly as it appears on the check. Be sure current address is shown.
C Claim numbers and suffixes are printed here on checks beneath the data for the type of payment shown here. Check the Green Box for the location of prefixes and suffixes for other types of payments.
F Type of payment is printed to the left of the amount.
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
Joint account holders should immediately advise both the Government agency and the finanacial institution of the death of a benficiary. Funds deposited after the date of death or ineligibility except for salary payments, are to be returned to the Government agency. The Government agency will then make a detemination regarding survivor rights, calculate survivor benefit payments, if any, and begin payments.
CANCELLATION
The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the Federal agency or by death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should notify the receiving financial institution that he/she is doing so.
The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient a written notice 30 days in advance of the cancellation date. The recipient must immediately advise the Federal agency if the authorization is cancelled by the financial institution. The finanacial institution cannot cancel the authorization by advice to the Government agency.
CHANGING RECEIVING FINANCIAL INSTITUTIONS
The payee's Direct Deposit will continue to be received by the selected financial institution until the Government agency is notified by the payee, that the payee wishes to change the financial institution receiving the Direct Deposit. To effect this change, the payee will complete a new SF 1199A at the newly selected financial institution. It is resommended that the payee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institution receives the payee's Direct Deposit payment.
FALSE STATEMENTS OR FRAUDULENT CLAIMS
Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for presenting a false statement or making a fraudulent claim.