Form SSA-1199-(Canada) Direct Deposit Sign-Up Form (Canada)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (CANADA)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
MONTHLY BENEFITS BY DIRECT DEPOSIT
x
x
x

Complete Section 1 and “SIGN YOUR NAME.”
Ask your bank to complete Section 3.
Mail completed form back using address in Section 2

Change #3

SECTION 1 (COMPLETED BY PAYEE)
Name and Complete Mailing Address:

- SOCIAL SECURITY CLAIM NUMBER -

B.I.C

Change #2
Name of Person Entitled to the Benefits

THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)

Change #5
TYPE
TELEPHONE NUMBER:
Change #7
PAYEE CERTIFICATION

Change #4

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.

I (beneficiary or representative payee) certify that I have read and
understand the back of this form. In signing this form, I authorize the
Social Security Administration to send this payment to the financial
institution indicated in Section 3 and deposit it in the designated
account. I understand that personal information in these payments is
confidential, but I consent to disclosure of payment information
compelled by law or necessary to protect against fraud or crime.

YOUR SIGNATURE

AMOUNT

Change #8

DATE

JOINT AC
JOIN
ACCOUNT
COUNT
OUN HOLDER’S
DER’S SIGNATURE
SIGNA

DATE

Change #10
ARE YOU THE REPRESENTATIVE PAYE? Yes

N
No
o

This account is:
My own account

A joint account

Change #9

BENEFICIARY DATE OF BIRTH

Change #6

SECTION 2 (MAILING ADDRESS)

GOVERNMENT AGENCY NAME:

MAIL COMPLETED FORMS TO:

Social Security Administration
Office of International Operations
PO Box 17769
Baltimore, MD 21235-7769
USA

SOCIAL SECURITY ADMINISTRATION

SECTION 3 (COMPLETED
INSTITUTION))
COMPLE D BY YOUR FINANCIAL INSTITUTION
THIS ACCOUNT MUST BE IN ____

NAME OF BANK

Change #11

BANK PHONE NUMBER

ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL

Canadian Dollar:

SIGNATURE OF BANK OFFICIAL

Checking

Savings

U.S. Dollar:

Checking

Savings

A) U.S. dollar account at Royal Bank of
Canada:

B) U.S. dollar account at any other financial
institution in Canada:

C) Canadian dollar account at any financial
institution in Canada:

RTN: 026004093
Transit Number:
_0 __ __ __ __ (5 digits, begins with zero)
Account Number:
__ __ __ __ __ __ __ (Must be 7 digits, begins
with 4 or 8, no dash)

RTN: 62
Transit Number:
__ __ __ __ __
Institution Number:
__ __ __
Account Number:
__ __ __ __ __ __ __ __ __ __ __ __

RTN: 51
Transit Number:
__ __ __ __ __
Institution Number:
__ __ __
Account Number :
__ __ __ __ __ __ __ __ __ __ __ __

ALL: No dashes, except Caisse Populaire 815 & 829 before 7th digit, 865 before 6th digit (which is always 2). POMS GN 02402.300.

Form SSA-1199-CN (7/2010)

Change #12

IMPORTANT INFORMATION - PLEASE READ CAREFULLY

The information you give on this form is confidential. We need the information to send your U.S. Social
Security payments electronically to your _____ bank account.
WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS

Change #13
You will receive your payment through the _____banking system and will usually be in your bank account shortly
after the regular payment date. With direct deposit, you will have immediate access to your money. This is the safest
way of receiving your benefits.
INFORMATION ABOUT CURRENCY CONVERSION

Change #14
With direct deposit, your U.S. Social Security payment converts automatically
ally to _
_____ (if applicable) at the daily
international exchange rate before deposited to your account.
**SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS**
If you have a joint account with a person who receives Social Security payments, and that person dies, you must
immediately contact your bank and the Social Security Administration or the American Embassy or Consulate in
your area. You must return to Social Security any payments deposited into a joint account after the death of a
beneficiary.
IF YOUR ADDRESS CHANGES
If your address changes, you must inform the American Embassy or the Social Security Administration. Your
payments may stop if the Social Security Administration needs to contact you and cannot find your location.
CHANGING BANKS OR BANK ACCOUNTS
If you change your bank or your account, you must notify one of these offices:
American Embassy/Consulate
Address of the American
Embassy/Consulate

Social Security
Administration
Office of International
Operations
PO Box 17769
Baltimore, MD 21235-7769
USA

You may need to fill out a new sign-up form. Do not close your old account until payments have started
coming to your new account.
PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management
and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov.
Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.
Form SSA-1199-UK (3-2007)

DIRECT DEPOSIT SIGN-UP FORM (Canada), Form SSA-1199-CN
Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act Statement Attached

Section 204 (a)(1) of the Social Security Act, as amended (42 U.S.C. 404), and 31 CFR 210, authorizes us to collect
this information. We will use the information you provide to process Social Security benefit payments with your
financial institution and/or its agent. The information you provide on this form is voluntary. However, failure to
provide all or part of the requested information may affect the processing of this form and may delay or prevent the
receipt of your benefit payments through the Direct Deposit/Electronic Funds Transfer Program.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
However, we may use it for the administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are
not limited to the following:
1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;
2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3.To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and
4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State, or local government agencies. Information from these matching
programs can be used to establish or verify a person’s eligibility for Federally-funded and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled, Claims
Folder System, 60-0089 and Master Beneficiary Record, 60-0090. These notices, additional information regarding
this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at
your local Social Security office.

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to process Social Security benefit payments with your
financial institution and/or its agent.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may affect the processing of this form and may delay or prevent the receipt of your
benefit payments through the Direct Deposit/Electronic Funds Transfer Program.
We rarely use the information you supply for any purpose other than to process Social Security
benefit payments with your financial institution and/or its agent. We may also disclose
information to another person or to another agency in accordance with approved routine uses,
which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and to private entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notices
entitled, Claims Folders Systems, 60-0089 and Master Beneficiary Record, 60-0090. These
notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.