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

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (SAMPLE)
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: (No P.O BOX address
allowed)

- 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

AMOUNT

EMAIL ADDRESS:

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

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

NO
This account is:
My own account

Beneficiary Date of Birth

A joint account

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:

MAIL COMPLETED FORMS TO:

Federal Benefits Unit
U.S. Embassy
Av. Republica de Colombia #57
Santo Domingo
Dominican Republic
FBU.Santo.Domingo@ssa.gov
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)

SOCIAL SECURITY ADMINISTRATION

THIS ACCOUNT MUST BE IN [Currency]

NAME OF BANK
ADDRESS OF BANK

BANK PHONE NUMBER

PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL

TYPE OF ACCOUNT:
Bank Code

Checking

Savings
Branch Code

Account Number

Print the entire SWIFT/BIC code in the blocks below

Form SSA-1199-OPXX

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 [Country] bank account.

WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
You will receive your payment through [Country] 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 [Currency] (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 the 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:
Federal Benefits Unit
U.S. Embassy
Av. Republica de Colombia #57
Santo Domingo
Dominican Republic

FBU.Santo.Domingo@ssa.gov

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.

Form SSA-1199-OPXX

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, 2003 at 68 FR 15784,
and 60-0090, entitled Master Beneficiary Record, as published on FR 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 1-800-772-1213 (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.