United American Insurance Company Fillable Forms
STANDARD FORM 1199A (Rev. 9/83) Prescribed by Treasury Department Treasury Dept. Cir. 1076 OMB No. 1510-0007 Expiration Date 1/31/90 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 mail this form to the financial institution. The financial in- stitution will verify the information in sections 1 and 2, and will com- plete Section 3. The completed form will be returned to the Govern- ment agency identified below MorePRINT OR TYPE REPRESENTATIVE'S NAME. SIGNATURE OF REPRESENTATIVE. TELEPHONE NUMBER. DATE. STANDARD FORM 1199A. (Rev. 9/83). Prescribed by Treasury Less
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