SSA-1199-XXXX Direct Deposit Sign-Up Form

Approved OMB No. 0960-XXXX

DIRECT DEPOSIT SIGN-UP FORM – country: _________________

APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY

MONTHLY BENEFITS BY DIRECT DEPOSIT

Please complete and sign Sections 1 and 2 . **Sign your name.** Ask your bank to complete Section 3. Mail the completed form in the envelope provided.

SECTION 1 Name and Complete Mailing Address

Name

The type of account is: ____ Checking ____ Savings. The account is: ____ Only my account ____ A joint account

Street, Apartment

City, Province, Postal Code

Country

Social Security Claim Number: IMPORTANT

Name of Person Entitled to the Benefit

SECTION 2

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 necessary to protect against fraud or crime.		JOINT ACCOUNT HOLDERS CERTIFICATION I certify that I have read and understand the back of this form, including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
SIGNATURE	DATE	SIGNATURE	DATE
YOUR DAYTIME TELEPHONE NUMBER

SECTION 3 (Ask your bank to complete this section.)

This account must be (in local currency.)/(a U.S. dollar account.)

NAME OF BANK
ADDRESS OF BANK
COUNTRY WHERE BANK IS LOCATED
BANK PHONE NUMBER		SIGNATURE OF BANK OFFICIAL

Print the routing and account numbers for this account, or Print the IBAN.

Bank and Branch Routing Number

Account Number

IBAN

Mail completed form to: Social Security Administration

Office of International Operations

PO Box 17769

Baltimore, MD 21235-7769

Form SSA-1199-XXXXX (3/2007) USA

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 in the country you named on page 1.

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 shortly after the U.S. payment date. You will no longer have to wait 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 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 the 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. Any Social Security payments deposited into a joint account after the death of a beneficiary 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.

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 in your country

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

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

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, 6401 Security Blvd, Baltimore, MD  21235-6401. Only comments relating to our time estimate should be provided, not the completed form.

Form SSA-1199-XXXXX (3/2007)