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Get FS 1200 2020-2024

FMS Form 1200 July 2009 Previous versions obsolete OMB No. 1510-0007 DIRECTIONS Please read the information on page 2 before completing this form. You must complete boxes A B C D E and F. Only complete this form to sign up for direct deposit if you are an individual or a representative payee of an individual who receives checks for the following types of federal benefits social security supplemental security income railroad retirement civil non-military retirement or VA compensation or pension only. Sign-Up Form for Direct Deposit You may also sign up online today at www. GoDirect. org or call Go Direct toll free at 1 800 333-1795 of Federal Benefit Payments for social security railroad retirement board civil non-military retirement payments or VA only. If you currently receive your payment by direct deposit you may not use this form* Please refer to page 2 for further instructions. A. FEDERAL BENEFIT RECIPIENT INFORMATION B. BANK OR CREDIT UNION INFORMATION print name s and address exactly as they appear on your benefit check NAME OF PERSON ENTITLED TO GOVERNMENT BENEFITS BENEFICIARY REPRESENTATIVE PAYEE Yes if yes enter No name at right DEPOSITOR ACCOUNT TITLE name s on account NAME OF REPRESENTATIVE PAYEE Checking ADDRESS street route P. O. box apartment number CITY or APO/FPO 9-DIGIT ROUTING NUMBER see sample check below ACCOUNT TYPE STATE ZIP CODE Savings ACCOUNT NUMBER see sample check below do not include check number DAYTIME TELEPHONE NUMBER - SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS BENEFICIARY You may also attach a voided personal check. If you are depositing into a savings account you may need to contact your financial institution to obtain the routing and account numbers. C. TYPE OF PAYMENT check only one 111999087 9876554321 ROUTING NUMBER SAMPLE CHECK bottom left corner CHECK NUMBER You must complete a separate form for each type of federal payment. SUPPLEMENTAL SECURITY INCOME VA COMP/PENSION ONLY For military federal salary veterans benefits or other federal payments not available through Go Direct please contact the paying agency see page 2 for a partial list of paying agencies. RAILROAD RETIREMENT specify below Annuity Unemployment benefit survivor benefit D. IDENTIFICATION CIVIL NON-MILITARY RETIREMENT Survivor Retirement E* PAYMENT VERIFICATION CLAIM NUMBER OR In order to process your request either the claim number found on documents from your paying agency or the check number from your last payment found in the upper right-hand corner of your Treasury check must be entered at left. You must also enter the amount of your last benefit payment. AMOUNT OF YOUR MOST RECENT PAYMENT F* CERTIFICATION I certify that I am entitled to receive the payment identified above and that I have read and understand the back of this form* In signing this form I authorize this payment to be sent to the financial institution named in Part B above to be deposited into the account above. FOR JOINT ACCOUNT HOLDERS SIGNATURE DATE HOLDERS on the back of this form* Be sure to complete all sections of this form* Otherwise the form cannot be processed* Return the completed form to This form is only to be used for switching from check payments to direct deposit of certain federal benefits listed in Box C.

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