U.S. Office of Personnel Management Retirement Services and Management Group Post Office Box 440 Boyers, PA 16017-0440 Form Approved OMB No.: 3206-0226 Date: It's Time to Sign Up for Direct Deposit Public Law 104-134 requires that most Federal payments be made by Direct Deposit. More than 90% of Federal retirees and survivors receive their payments by Direct Deposit. We recommend that you participate too. We can make payment by Direct Deposit into your account in a bank, credit union, savings bank, or thrift institution. Many financial institutions offer basic, low-cost accounts, as well as full-service accounts. Direct Deposit is safe, reliable, and convenient for you. You do not have to take care of a paper check (which could be delayed in the mail, lost, or stolen). However, if receiving your payment electronically would cause you a hardship because you have a disability or because of a geographic, language, or literacy barrier, you may receive your payment by check. In addition, if enrolling in Direct Deposit would cause you a financial hardship because it would cost you more than receiving your payment by check, you may receive your payment by check. For more information about Direct Deposit, call us on 1-888-767-6738 (TDD: 1-800-878-5708) Monday through Friday from 7:30 AM to 7:45 PM Eastern time. It is easy to sign up. You can call us toll-free using the numbers shown above. If you do not want to call us to enroll, you can fill this form out and FAX it to 724-794-6633. Or, you can mail this form to our Boyers, Pennsylvania, address shown at the top of this page. Retirement Services Program Enclosure: Return Envelope Public Burden Statement We think this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management, OPM Forms Officer (3206-0226), Washington, DC 20415-7900. The OMB Number 3206-0226 is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Prior versions of this form are not usable. RI 38-128 Revised March 2007 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's name Claim number Direct Deposit Information To have your annuity payments made by Direct Deposit, please complete Section A. You may also receive Direct Deposit by calling us or by completing a Standard Form 1199A (available at most financial institutions). If you want payments by check, please complete Section B. Section A - Payment by Direct Deposit I want to receive my annuity payments by Direct Deposit into the account indicated below. Account Information - Please contact your financial institution to obtain accurate and complete account and routing numbers. If you prefer, you may attach a voided check instead of entering the account and routing numbers. However, we cannot accept a deposit slip for this purpose. Account type Account number Checking Savings Financial institution routing number Name, address and telephone number of your financial institution ( ) Your signature* Your daytime telephone number ( Date ) Section B - Payment by Check Please pay me by check; Direct Deposit would cause me a hardship as described on the other side of this notice. I understand that I may sign up for Direct Deposit at any time. Your signature* Your daytime telephone number ( Date ) *You must sign. We cannot accept the signature of a person holding your power of attorney. We can accept the signature of an OPM-approved representative payee or a court-appointed fiduciary, if we have a copy of the court appointment. Reverse of RI 38-128 Revised March 2007 American LegalNet, Inc. www.FormsWorkFlow.com