Standard Form 1199A Direct Deposit Authorization

Information you will need

• What’s the payee’s full name?
• What’s the account type?
• What’s the payee’s address?
• What’s the payee’s city?
• What’s the payee’s state?
• What’s the payee’s zip code?
• What’s the payee's claim or payroll ID number?
• What’s the bank account number?
• What’s the payment type? (if applicable)
• What’s the payment amount? (if applicable)
• What’s the government agency name?
• What’s the government agency’s address?
• What’s the payee’s phone number?
• What’s the payment type?

Completed by the recipient and the beneficiary and the agent.