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

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM CAMBODIA
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 completed form back using address in Section 2

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

- SOCIAL SECURITY CLAIM NUMBER -

B.I.C
(Optional)

Name of Person Entitled to the Benefits

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

TELEPHONE NUMBER:

PAYEE 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.
YOUR SIGNATURE
DATE

ARE YOU THE REPRESENTATIVE PAYEE? YES
Beneficiary Date of Birth

NO

AMOUNT

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.

SIGNATURE

DATE

This account is:
My own account

A joint account

(Month/Day/Year)

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:

MAIL COMPLETED FORMS TO:

American Embassy
1201 Roxas Boulevard
Ermita, Manila 0930
Philippines
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)

SOCIAL SECURITY ADMINISTRATION

THIS ACCOUNT MUST BE IN UNITED STATES DOLLAS (USD)

)NAME OF BANK

BANK PHONE NUMBER

ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL
TYPE OF ACCOUNT:

Account Number

Form SSA-1199-OP7 (7/2010)

Checking

Savings
Print the entire SWIFT/BIC code in the blocks below.

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 Cambodia bank account.

WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
You will receive your payment through the Cambodia 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 USD (if applicable) at the daily
international exchange rate before being 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 Federal Benefits Unit 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 Federal Benefits Unit 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
1201 Roxas Boulevard
Ermita, Manila 0930
Philippines

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

You may need to fill out a new Direct Deposit sign-up form. Do not close your old account until payments
have started coming to your new account.

PAPERWORK REDUCTION ACT STATEMENT

Please See Revised Privacy Act and
PRA(Provided
Statements
attached.
By Reports
Clearance)

Form SSA-1199-OP7 (7/2010)

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent you from receiving benefit payments through foreign financial
institutions.
We will use the information you provide to process benefit payments with your financial
institution. We may also share your information for the following purposes, called routine uses:


To the Department of State and its agents for administering the Act in foreign countries
through facilities and services of that agency; and



To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2004, at 68 FR 15784, and 60-0090, entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826. Additional information and a full listing of all our
SORNs are available on our website at https://www.ssa.gov/privacy.

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 1-800772-1213 (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.