Government Direct Deposit Sign-Up Form Template

Payee Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]

Government Agency Name: [Agency Name]
Program or Payment Type: [Benefit / Retirement / Refund / Other]
Agency Address: [Address]

1. Payee Information

Full Name: [Full Name]
Social Security Number / Claim Number / ID Number: [Number]
Date of Birth: [Date of Birth, if applicable]
Mailing Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]

2. Payment Information

Type of Government Payment:

☐ retirement benefits
☐ disability benefits
☐ veterans benefits
☐ tax refund
☐ salary or wages
☐ other: [Describe]

Agency or Program Name: [Agency or Program Name]
Claim, Case, or Reference Number: [Number, if applicable]

3. Financial Institution Information

Bank or Credit Union Name: [Financial Institution Name]
Branch Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]

Routing Transit Number: [Routing Number]
Account Number: [Account Number]

Account Type:

☐ checking
☐ savings

4. Deposit Authorization

I authorize the government agency identified in this form to deposit payments directly into the financial institution account listed above.

I understand that this authorization will remain in effect until changed or revoked according to applicable agency procedures.

5. Change or Cancellation

This request is for:

☐ new direct deposit enrollment
☐ change of financial institution
☐ change of account number
☐ cancellation of prior deposit instructions
☐ other: [Describe]

Effective date requested, if applicable:

[Date]

6. Payee Certification

I certify that the information provided in this form is true and correct to the best of my knowledge.

I understand that incorrect or incomplete information may delay processing of my direct deposit request.

7. Payee Signature

Payee Signature: __________________________
Name: [Full Name]
Date: [Date]

8. Financial Institution Certification

The financial institution named above confirms that the account information listed in this form is associated with the payee or otherwise eligible to receive the direct deposit described.

Authorized Bank Representative Signature: __________________________
Name: [Full Name]
Title: [Job Title]
Date: [Date]

9. Agency Use Only

Agency Representative Name: [Full Name]
Department: [Department Name]
Date Received: [Date]
Reference Number: [Number]
Comments: [Comments]