SSA-1199--Current Form

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Approved OMB No. 0960-XXXX
0686

DIRECT DEPOSIT SIGN-UP FORM (Country)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
MONTHLY BENEFITS BY DIRECT DEPOSIT
Please make any necessary changes in Section 1A. Complete and sign Section 2. Ask your bank to complete Section 3.
Mail the completed form in the envelope provided.
SECTION 1 If the address below is incorrect or if it is your
bank's address, please complete Section 1A.

SECTION 1A If the address in Section 1 is incorrect or if it
is your bank's address, please print your correct mailing
address below.
ADDRESS CHANGE

Person Entitled to Payment

1
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PAYEE CERTIFICATION
I certify that I have read and understand the back of this form. In signing
this form, I authorize the Social Security Administration to send my payment
to my bank and deposit it in the designated account. I understand that
personal information in these payments will be treated confidentially, but I
consent to disclosure of payment information that is compelled by law or
necessaly to protect against fraud or crime.

JOINT ACCOUNT HOLDEROS CERTIFICATION
I certify that I have read and understand the back of this form, including the
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.

SIGNATURE

SIGNATURE

1

DATE

1

DATE

This account is:

YOUR DAYTIME TELEPHONE NUMBER

My own account

A joint account

SECTION 3 (Ask your bank to complete this section.)
This account must be in (local currency).
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NAME OF BANK
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ADDRESS OF BANK

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SIGNATURE OF
BANK OFFICIAL

BANK PHONE NUMBER
Bank Code

Branch Code

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Account Number

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MAIL THE COMPLETED FORM TO OUR AGENTS FOR INTERNATIONAL DIRECT DEPOSIT IN (COUNTRY) AT:
International Direct Deposit
Federal Reserve Bank of New York
E. Rutherford Operations Ctr.- 1 Floor
100 Orchard Street
East Rutherford, NJ 07073
USA

Form SSA-1199-(Country) (0812003)

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PAPERWORK REDUCTION ACT STATEMENT
This information 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. You may send comments on our time estimate above to: SSA, 1338 Annex building,
Baltimore, MD 21235-0001. Only comments relating to our time estimate should be provided, not the completed
form.

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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's) bank account.

WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
Your payment will be sent through the (Country's) banking system and will usually be in your bank
account 1 day after the U.S. payment date. You can avoid waiting up to 15 working days for your
check to clear. With direct deposit you will have immediate access to your money.

INFORMATION ABOUT CURRENCY CONVERSION
With direct deposit, you will not need to pay up to $10 to cash your check and get your U.S. dollars
converted to (local currency). A few days before the payment date, your U.S. Social Security
payment is automatically converted at an interbank exchange rate, which is generally better than the
rate offered by banks in (Country) on that day.

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 U.S. Social Security Administration.
Social Security payments deposited into a ioint account after the death of a beneficiarv must be
returned to Social Security. As soon as we are advised of the death, if you are eligible to receive
Social Security, we will determine whether your benefit amount will change and will send you any
money that we owe you.

AnV

IF YOUR ADDRESS CHANGES
If your address changes, you must inform the U.S. Social Security Administration. If the Social
Security Administration has to contact you and cannot locate you, your payments may be stopped.

CHANGING BANKS OR BANK ACCOUNTS
If you change your bank or your account, you must notify one of the offices below:
Federal Benefits Unit
American Embassy
(Address)
(Country)

International Direct Deposit
Federal Reserve Bank of New York
E. Rutherford Oper. Ctr.- lS'
Floor
100 Orchard Street
East Rutherford, NJ 07073

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

Do not close vour old account until payments have started coming to your new account.