CM-11-08-160ROUND ROCK, TEXAS
PURPOSE. PASSION. PROSPERITY.
Item Caption:
Approval Date:
City Manager Approval Summary Sheet
Consider executing a Direct Deposit Sign -Up form
05 -Aug -2011
Department:
Finance
Project Manager:
Cheryl Delaney
Item Summary:
This item is a direct deposit form signed by the City and Bank of America required by the Department of Housing and
Urban Development (HUD) in accordance with the Main Street grant B1OSPTX1041.
Strategic Plan Relevance:
8.0 — Maintain and enhance public confidence, satisfaction and trust in City Government
Cost: N/A
Source of Funds: N/A
REV. 6/10/10
Standard Form 1199A (EG)
(Rev. June 1987)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
• The claim number and type of
Government
• 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
mail 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 ret
identified below. urned to the Government agency
• A separate form must be completed for each type of payment to be
sent by Direct Deposit.
A NAME OF PAYEE (last, first, middle initis
City of Round Rock, Texas
ADDRESS (street, route, P.O. Box, APO/FPO)
221 E. Main Street
OMB No. 1510-0007
information is also stated
checks. (See the sample checpayment are I onthe bakof ton
this form) This
on beneficiary/annuitant award letters and
other documents from the Government agency.
• Payees must keep the Govemment address
changes in order to receive important information oabut benefits
remain qualified for payments.
and to
SECTION 1 (TO BE COMPLETED BY PAYEE)
CITY
Round Rock
STATE
TX
TELEPHONE NUMBER
AREA CODE 512-218-5400
B NAME OF PERSON(S) ENTITLED TO PAYMENT
City of Round Rock
C CLAIM OR PAYROLL ID NUMBER
Prefix
ZIP CODE
78664
PAYEE/JOINT PAYEE CERTIFICATION
I 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, I
authorize my payment to be sent to the financial institution named below
to be deposited to the designated account.
�/�-J,- _ •I DATE
SIGNATU
Steve Norwood, City Manager
D TYPE OF DEPOSITOR ACCOUNT CHECKING ❑
E DEPOSITOR ACCOUNT NUMBER
DD0UDODiJ 0001111
F TYPE OF PAYMENT (Check only one) •
0 Social Security
0
0 Supplemental Security Income Fed. Salary/Mil. Civilian Pay
❑ Railroad Retirement
0 Civil Service Retirement (OPM)
0 VA Compensation or Pension
Mil. Active
0 Mil. Retire.
0 Mil. Survivor
® Other Grant B -10 -SP -TX -0141
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY(
t(if applicable)
AMOUNT
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.
SAVINGS
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
GOVERNMENT AGENCY NAME
City of Round Rock, Texas GOVERNMENT AGENCY ADDRESS
221 E. Main Street
Round Rock, Texas 78664
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
NAME AND ADDRESS OF FINANCIAL INSTITUTION
Bank of America ROUTING NUMBER
515 Congress Avenue
Austin, Texas 78701-3502
DEPOSITOR ACCOUNT TITLE
City of Round Rock Operating Account
FINANCIAL INSTITUTION CERTIFICAT
I confirm the identityf th
NSN 7540-01-058-0224
o e above-named payee(s) and the account number and title. As reON
presentative of the above-named financial institution,
financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR P
REPRESENTATIVE'S NAME T TIVarts 240, 209, and
k 0 j) O r� SI% TU E OF REPRE NE
0. 1.
TELEPHONE NUMBER
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT A ENC E i / 9
Financial Institu . ns should refer to the GREEN BOOK for further instructions.
GOVERNMENT AGENCY COPY Y IDENTIFIED ABOVE.
-LI-06-(-12D
DAT
Designed using Perform Pro, WHS/DI1199-207
OR, Mar 97