HomeMy WebLinkAboutSection 1SF .1199A - Direct Deposit Sign -Up Form
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SECTION 1 (TO BE COMPLETED BY PAYEE)
Standard Form 1199A - Direct Deposit Sign -Up Form
A ORGANIZATION NAME
City of Miami Department of Fire Rescue
ADDRESS (street, route, P.O. Box, APO/FPO)
1151 NW 7 Street 3rd Floor
CITY STATE ZIPCODE
Miami Florida 33136 -3604
B NAME OF PERSON(S) ENTITLED TO PAYMENT
Pete Chircut
C CLAIM OR PAYROLL ID
NUMBER Suffix
Prefix 59-6000375
PAYEE/JOINT PAYEE CERTIFICATION
I certify that I am entitled to the payment identified above. In signing this
form, authorize my payment to be sent to the financial institution named
below to be deposited to the designated account.
SIGNATURE DATE
SIGNATURE
DATE
/ /
OMB No 151-0007
D TYPE OF DEPOSITOR ACCOUNT
Checking
E DEPOSITOR ACCOUNT NUMBER
2696204833948
F TYPE OF PAYMENT
Other, Grant Award
EMW-2004-FG-08448 , EMW-2005-FF-02434
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE AMOUNT
JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
1 certify that I have read and understood the instructions, Including the SPECIAL
NOTICE TO JOINT ACCOUNT HOLDERS.
SIGNATURE
SIGNATURE
SECTION 2
GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS
DATE
/ 1
DATE
/ /
Federal Emergency Management Agency Attn: Assistance to Firefighters Grant Program
Grants Management Branch, Room 350, 500 C Street S.W., Washington, D. C. 20472
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK DIGIT
DEPOSITOR ACCOUNT TITLE
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 certlfy 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
SIGNATURE OF REPRESENTATIVE TELEPHONE NUMBER DATE
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