Auth Deposit Recurring Pyments Standard Form 1~99A (Rev. 1-78)
Department of Treasury--Fiscal Service
Treasury Dept. CAr. 1076
AUTHORIZATION FOR DEPOSIT OF FEDERAL RECURRING PAYMENTS
RECIPIENT (PAYEE) TO COMPLETE ITEMS A THROUGH J
I (we) authorize and request the below indicated program agency to direct the net amount of the below indicated Federal ~e~urring p~yment 'fi~
crediting in my (our) account indicated at the financial organization designated below. This authorization is not an assignment Of my (our) right
receive payment and revokes all prior payment direction notifications applicable to these payments. I (we) understand that the 'financial organization
designated reserves the right to cancel this agreement by notice to me (us); however, this authorization will remain in effect with the program agency
until canceled by notice from me (us).
A CLAIM OR FiLE NUMBER B PROGRAM AGENCY C TYPE OF PAYMENT
cJ on ~49 6
300 ~ ASH ~ P. O. Box ~'i~ D.L. Ha~tson H.E.
SR'LINa KS ~ 67402-0746
O. L. ~rrtson - Flnan~ Director H.E. ~tt - Ct~ Tmasu~r
FINANCIAL ORGAN[ZATION TO COMPLETE BELOW THIS LINE
We, the ~low designated financial organization, hereby agree to receive and deposit sums for the payee(s) named herein, in accordance with 3] CFR
Pa~s 2~, 2~, and 210. We understand that our account number shown for the payee(s) named herein will be included on individual payment credits to
his (their) account. We understand that the payee(s) named a~ve has (have) the right ~o cancel this authorization and we reserve the right to cancel this
agr~ment by notice to the payee(s).
P~ ~ & T~s~
~t~, ~ 67401
~pEX~,N~BEROFDE~SiTORA~OUNTTOBECREDiTED R:1U'R~ FORM'1( =
C ~ ~9 6 ~INGION, O,C, 2~23~
City of ~ltna
,/] , 91~2~T221
The pa~s) who~ signature(s) appea~ above personally appeared before me, presented satisfactory identification, and, after being duly sworn,
acknowledged this to be his (her) (their) freely given act and deed.
/ Notary Public Date Sea~,~////Y~
.9~-ma RECIPIENT(S) COPY
IMPORTANT NOTICE--THIS FORM IS TO BE USED FOR ALL FEDERAL RECURRING PAYMENTS EXCEPT SOCIAL SECURITY. USE
SF-1199 FOR SOCIAL SECURITY PAYMENTS.
If you wish your Federal recurring payments sent to your financial organization for deposit into your savings or checking account, both you and the
financial organization must complete this form to authorize this action. The U.S. Government will forward these payments to the point you authorize.
The financial organization may be any bank, savings bank, savings and loan association or similar institution, or Federal or state chartered credit union. If
you do not have an accounl in one of these organizations and wish one, contact the financial organization of your choice.
THIS FORM ONLY AUTHORIZES DEPOSITS INTO YOUR ACCOUNT--IT DOES NOT AUTHORIZE P/ITHDI~P/ALS FROM YOUR
ACCOUNT
RECIPIENT (PAYEE) FORM COMPLETION INSTRUCTIONS
ITEM A--Print ibc claim number or file number that the program agency requires for processing your records. This information can be obtained from
the check, award letter, or other correspondence from the program agency.
ITEM ~The program agency is the Government agency from which you receive payments. Print the applicable program agency designation as
follows:
For Civil Service Commission, print "CSC'. For Railroad Retirement, print "RRB".
For Veterans Administration, print "VA". For Government Employee Salary, print agency name.
ITEM C--Print the type of payment which you wish deposited.
I. If Civil Service payments, print "ANNUITY". 3. If Railroad Retirement, print "ANNUITY".
2. If Veterans payments, print "COMP", "PENS". 4. If Employee Salary, print "SALARY".
or "INSURANCE".
A SEPARATE FORM MUST BE COMPLETED FOR EACH TYPE OF PAYMENT WHICH YOU WISH DEPOSITED IN YOUR ACCOUNT.
ITEM D~Print the name of the person(s) to whom the payment is made.
ITEM E~Show the type of account and the account number for the account in which this payment is to be deposited. The account may be either a
savings or a checking account. If you do not know the account number, it may be obtained from your financial organization.
ITEM F--Print the mailing address of the recipient named in Block D. Provide a complete address including Zip Code.
ITEM G--Print the name(s) of the person(s) for whom the payment is made. This is the person(s) entitled to the proceeds of the payment. If you are the
recipient(s) of the payment and are entitled to the proceeds, you should print your name(s). If you are a representative payee, print the name
of the person(s) for whom you receive payment under this account.
ITEM H~THIS BLOCK IS TO BE USED FOR CIVIL SERVICE PAYMENTS ONLY. If you are a Civil Service survivor annuitant, give the name
of the deceased Federal Employee on whose service your survivor annuity payments are based.
ITEM/--Print the telephone number; including the Area Code, of the recipient(s) named in Item D.
ITEM.l--Sign and date the form. If both parties of a joint payment desire to have their payment deposited into one account, both parties must sign the
form. If only one party of a joint payment desires to have his portion of the payment deposited, only that one party's name in Item D and
signature in Item J should appear on the form. If your signature is made by mark, it must be witnessed by two persons who sign the form. If
witnesses are required, they should print the word "Witness" above their signatures to the right of your mark.
After completion of the top half of this form, all three (3) copies should be delivered or sent to the designated financial organization. After completion,
the original of this form is to be furnished to your program agency. The first copy is to be retained by the financial organization and the last copy is to be
retained by you.
CANCI~LLATION INSTRUCTIONS
P/hen entered in your record with the program agency, this authorization will remain in effect until canceled by notice to the program agency by one or both
recipients or in the event of death of any recipient or any person for whom this payment is made. The financial organization sbouM also be notified if you cancel
thi~ agreement.
The financial organization may cancel their agreement by providing you a written n~tice 30 days in advance of the ?ncellat!~n date. You must advise the
program agency immediately if this authorization is canceled. The financial organizatton cannot cancel this authorizatton by advtce to the program ageno: