Form SSA-1199-(Country) Direct Deposit Sign-Up Form (Name of Country)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (COUNTRY NAME)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
MONTHLY BENEFITS BY DIRECT DEPOSIT
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Complete Section 1 and “SIGN YOUR NAME.”
Ask your bank to complete Section 3.
Mail completed form back using address in Section 2

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

BIC
(OPTIONAL)

- SOCIAL SECURITY CLAIM NUMBER -

Name of Person Entitled to the Benefits

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

AMOUNT

TELEPHONE NUMBER:
CERTIFICATION
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.

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

JOINT ACCOUNT HOLDER’S SIGNATURE

DATE

ARE YOU THE REPRESENTATIVE PAYEE? Yes

No

This account is:
My own account

DATE

A joint account

BENEFICIARY DATE OF BIRTH

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
SOCIAL SECURITY ADMINISTRATION

MAIL COMPLETED FORMS TO:

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN

NAME OF BANK

BANK PHONE NUMBER

ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL

BENEFICIARY ID

CNAPS CODE

Type of Depositor Account

Checking

Account Number

Bank
Number/Code

Bank Sorting
Code

Canadian Account
Number

Check Char (CIN)

Check Digit Code

Country Code

Debit Card
Number

Deposit Account
Number (DAN)

Institution Code

Routing and
Transit Number
(RTN)

Society for
Worldwide
Interbank Financial
TelecommunicationBusiness Identifier
Code (SWIFT-BIC)

Mexican Bank
Association (ABM)
number

National Identity
Document

Form SSA-1199- (07/2010)

Bank State Branch
Number/Code
China National
Advanced Payment
System (CNAPS)

Savings
Beneficiary ID
Codigo de Cuenta
Interbancario (CCI)
Code
Korean
Registration
Number

Tax ID number

Branch
Number/Code
Control Code
Locality

International
Bank Account
Number (IBAN)

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
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:
With direct deposit, your U.S. Social Security payment is automatically converted 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 the following offices:

American Embassy

Social Security Administration
Office of Earnings and
International Operations PO Box
17769 Baltimore MD, 212357769
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-

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.