CM-09-04-056DATE: April 10, 2009
SUBJECT: Direct Deposit Form SF1199
ITEM: Consider executing Direct Deposit banking form.
Department:
Staff Person:
Finance
Cheryl Delaney, Finance Director
Justification: Payments from HUD will be made via direct deposit. HUD
needs a signed certification from an authorized signer on
behalf of the City to receive these direct deposit payments
on grant B -08 -SP -TX -0145.
Funding: N/A
Outside Resources: N/A
Background: The City has received project funding for grant project B-
08 -SP -TX -0145 from the US Department of Housing & Urban
Development. This will allow HUD to direct deposit
payments related to the grant into the City's Operating
Account.
Standard Form 1199A (EG)
(Rev. Jun 1987)
Prescribed by Treasury
Deparhnent
Treasury Dept. C. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
• To sign up for Direct Deposit, the payee Is to read the back of this form
and fill In the Information requested in Sections 1 and 2. Then take or
mall this form to the financial Institution. The financial Institution will
verify the information In Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Identified below.
• A separate form must be completed for each type of payment to be
sent by Direct Deposit.
OMB No.1 5100007
• The claim number and type of payment are printed on Govemment
checks. (See the sample check on the back of this form.) This
information is also stated on beneficiary/annuitant award letters and
other documents from the Government agency.
• Payees must keep the Government agency informed of any address
changes in order to receive important information about benefits and to
remain qualified for payments.
SECTION 1 (TO BE COMPLETED BY PAYEE
A NAME OF PAYEE (lest, first, middle Initial)
City of Round Rock, Texas
D TYPE OF DEPOSITOR ACCOUNT[ CHECKING SAVINGS
E DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
221 E. Main Street
0 0 4 7 9 5 8 4 6 8
2 1
0
CITY STATE ZIP CODE
Round Rock, TX 78664
F TYPE OF PAYMENT (Check only one)
❑ social Security ❑ Fed.
■ Supplemental Security Income 0 Mil. Adive
0 Railroad Retirement 0 Mil. Retire.
0 VA Retirement (OPM) 0 Mil. Survivor
C13
0 VA Coompenn,pen sation or Penebn El Other
Salary/Mil. Civilian Pay
TELEPHONE NUMBER
AREA CODE 512-218-5400
DEPOSITOR ACCOUNT TITLE
City of Ro ind Rock Operating Account
NAME OF PERSON(S) ENTITLED TO PAYMENT
of Round Rock
Grant B -08 -SP -TX -014.
Si RAE F R E TATIVE
if�L,v'^
C CLAIM OR PAYROLL ID NUMBER
Prefix Suffix
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY Of applicable)
TYPE
AMOUNT
PAYEE/JOINT PAYEE CERTIFICATION
certify that I am entitled to the payment Identified above, and that I have
read and understood the back of this form. In signing this form, 1
authorize my payment to be sent to the financial Institution named below
to be deposited to the designated account.
JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
I certify that I have read and understood the back of this form,
Including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
SI ATURE
DATE
Li -IC- ( u
SIGNATURE
DATE
SIG
Jar
A RE
s Nuse, City Manager
DATE
04/10/09
SIGNATURE
DATE
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
GOVERNMENT AGENCY NAME
City of Round Rock, TX
GOVERNMENT AGENCY ADDRESS
221 E. Main Street
Round Rock, TX 78664
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION
NAME AND ADDRESS OF FINANCIAL INSTITUTION
Bank of America
515 Congress Avenue
Austin, TX 78701-3502
ROUTING
1
NUMBER
1
1
I
—
0-
—
—
0
—
0
0
2
CHECK
DIGIT
5
DEPOSITOR ACCOUNT TITLE
City of Ro ind Rock Operating Account
FINANCIAL INSTITUTION CERTIFICATION
I confirm the Identity of the above-named payee(s) and the account number and title. As representative of the above-named financial Institution, I
certify that the financial Institution agrees to receive and deposit the payment Identified above in accordance with 31 CFR Parts 240, 209, and
210.
PRINT OR TYPE REPRESENTATIVE'S NAME
Nick London
Si RAE F R E TATIVE
if�L,v'^
TELEPHONE NUMBER
512-397-2664
DAT
/Wit)
Financial Instil should refer to the GREEN BOOK for further Instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 754e01-05ee224 PAYEE COPY
1199-207
Designed using Perform Pro. 'HSIDIDR, Mar 97