Form SSA-1199((United K SSA-1199((United K Direct Deposit Sign-Up Form (United Kingdom)

SECTION 1 (TO BE COMPLETED BY PAYEE)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (UNITED KINGDOM)

APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY

MONTHLY BENEFITS BY DIRECT DEPOSIT

• Complete Section 1 and “SIGN YOUR NAME.”

• Ask your bank to complete Section 3.

• Mail form back using address in Section 2

Name and Complete Mailing Address:		- SOCIAL SECURITY CLAIM NUMBER -
		Name of Person Entitled to the Benefits
		THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TELEPHONE NUMBER:		TYPE	AMOUNT
PAYEE CERTIFICATION I certify that I have read and understand the back of this form. In signing this form, I authorize the Social Security Administration to send my payment to my bank and deposit it in the designated account. I understand that personal information in these payments will be treated confidentially, but I consent to disclosure of payment information that is compelled by law or necessary to protect against fraud or crime.		JOINT ACCOUNT HOLDER’S CERTIFICATION (optional) I certify that I have read and understand the back of this form, including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
YOUR SIGNATURE	DATE	SIGNATURE		DATE
		T his account is: My own account A joint account

SECTION 2 (MAILING ADDRESS)

GOVERNMENT AGENCY NAME: SOCIAL SECURITY ADMINISTRATION

MAIL COMPLETED FORMS TO: U.S. EMBASSY FEDERAL BENEFITS UNIT 24 GROSVENOR SQUARE LONDON W1A 2LQ UNITED KINDON

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)

THIS ACCOUNT MUST BE IN GP POUNDS.

NAME OF BANK

BANK PHONE NUMBER

ADDRESS OF BANK

PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL

T YPE OF ACCOUNT: CHECKING SAVINGS

Bank Sorting Code Number

Account Number

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Form SSA-1199-OP21 (7/2010)