SSA-1199 - Current

Form SSA-1199-OP71 (03-2018)
Social Security Administration

DIRECT DEPOSIT SIGN-UP FORM (Cambodia)

Form Approved
OMB No. 0960-0686

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
Telephone Number:

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

Type

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

Yes

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.

Joint Account Holder's Signature

Date

Are you the Representative Payee?

Amount

No

This account is:
My own account

Beneficiary Date of Birth

Date

A joint account

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:

Mail Completed forms to:

SOCIAL SECURITY ADMINISTRATION

NAME OF BANK

American Embassy
1201 Roxas Boulevard
Ermita, Manila 0930
Philippines

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN U.S. DOLLARS (USD)
BANK PHONE NUMBER

PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL

Type of Depositor Account

Checking

Account Number

Print the entire SWIFT/BIC code in the blocks below

Savings

Form SSA-1199-OP71 (03-2018)

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 U.S. Dollars (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
1201 Roxas Boulevard
Ermita, Manila 0930
Philippines

Social Security Administration
Office of Earnings and 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 - 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-OP71 (03-2018)
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.