Form SSA-1199(Canada) Direct Deposit Sign-Up Form (Canada)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (CANADA)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
BENEFITS BY DIRECT DEPOSIT
¾
¾

Complete Sections 1, 2 & 3. **SIGN YOUR NAME**
If you want your benefits sent in U.S. dollars to your U.S. dollar account in Canada, ask your financial institution to complete
Section 4. If you want your benefits sent in Canadian dollars to your Canadian dollar account in Canada, ask your financial
institution to complete Section 5.
¾ Return the completed form to the address below. Include a VOIDED CHECK to help us code your International Direct Deposit.
SECTION 1
SECTION 2
Name
of Bank or Other Financial Institution:
Name and Complete Mailing Address:
Address of Financial Institution:

Financial Institution Phone Number:
(__ __ __) __ __ __ - __ __ __ __
The type of account is:

Social Security Claim Number – IMPORTANT:

___ U.S. dollar Checking
___ U.S. dollar Savings
___ Canadian dollar Checking
___ Canadian dollar Savings
The account is:
___ Only my account
___ A joint account

SECTION 3
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

Signature

Date

Date

Phone: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
SECTION 4 For direct deposit to your U.S. dollar account, ask your bank to complete A or B below.
A. U.S. dollar account at Royal Bank of Canada:
U.S. Routing number 026004093
Transit Number _0 __ __ __ __ (5 digits, begins with zero)

B.

U.S. dollar account at any other financial institution in
Canada:
Transit Number __ __ __ __ __
Institution Number __ __ __

Account number __ __ __ __ __ __ __ (Must be 7 digits, begins
with 4 or 8, no dash)

Account Number __ __ __ __ __ __ __ __ __ __ __ __
Bank Official’s Name (Please print.):

Bank Official’s Name (Please print.):
Phone Number: (_ _ _) __ __ __ - __ __ __ ___ Date:

Phone Number: (_ _ _) __ __ __ - __ __ __ __ Date:

SECTION 5 For direct deposit to your Canadian dollar account,
ask your bank to complete this section.

MAIL COMPLETED FORM
TO:
Office of International Operations
P.O. Box 17769
Baltimore, MD 21235-7769
USA
Please don’t write in this box: for SSA only.
RBC US$: RTN: 026004093;
DAN: 5 digit transit number, 7 digit account number.
Other US$: RTN: 62, 5 digit transit number, 0, U.S. check digit;
DAN: 3 digit institution number, account number up to 12 digits.
Can. $ all: RTN: 51, 5 transit number, 0, U.S. check digit.
DAN: 3 digit institution number, account number up to 12 digits.
th
ALL: No dashes, except Caisse Populaire 815 & 829 before 7
digit, 865 before 6th digit (which is always 2).
POMS GN 02402.300.

Canadian dollar account at any financial institution in
Canada:
Transit Number__ __ __ __ __ Institution Number __ __ __
Account Number __ __ __ __ __ __ __ __ __ __ __ __
Bank Official’s Name (Please print.):

Phone Number: (_ _ _) __ __ __ - __ __ __ __ Date
Form SSA-1199-CN (3/2007)

IMPORTANT INFORMATION – PLEASE READ CAREFULLY
Now you have two choices! Social Security benefits can now be directly deposited in either your Canadian
dollar account or your U.S. dollar account in Canada.
It is time to have your benefits delivered directly into your bank account!
Direct Deposit is safer and more convenient than checks.
The information you give on this form is confidential. We need this information to send your U.S. Social
Security payment directly to your account at a financial institution in Canada.
How do I sign up?
It’s easy!
1. On the other side of this form, complete Sections 1, 2, and 3. Remember to sign your name.
2. If you want your benefits sent to your U.S. dollar account, ask your bank to complete Section 4.
3. If you want your benefits sent to your Canadian dollar account, ask your bank to complete Section 5.
4. Mail the completed form in the envelope provided. Include a voided check, if possible.
What exchange rate will be used if I get Canadian dollars?
Your Social Security benefit will be converted to Canadian dollars at a very good rate a few days before it is
deposited in your account. The rate may be different from the rate on the day you receive your payment.
What if I change my account?
If you change your financial institution or your account, you must notify Social Security at either your servicing
office or the address below. Do not close your old account until benefits start coming to your new
account.
What if I have a joint account?
If you have a joint account, the other account holder should sign the Joint Account Holder’s Certification on the
front of this form. If you have a joint account with a person who receives Social Security payments, and that
person dies, you must let the Social Security Administration know right away. 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, we will let you know if your benefit amount will change and we’ll send you any
money we owe you.
If you have any questions, ask any Social Security office or the office below.
Social Security Administration
Office of International Operations
P.O. Box 17769
See revised Privacy Act and
Baltimore, MD 21235-7769
Paperwork Reduction Act
USA

statements below.
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-CN (3/2007)

DIRECT DEPOSIT SIGN-UP FORM (Canada), Form SSA-1199-CN
Privacy Act Statement
Collection and Use of Personal Information
Section 204 (a)(1) of the Social Security Act, as amended (42 U.S.C. 404), and
31 CFR 210, 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. The information you provide on this form is voluntary.
However, failure to provide all or part of the requested 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 provide on this form for any purpose other than for
the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. 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, General
Services Administration, National Archives Records Administration, and the
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 of Social Security programs.
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 and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of
Records Notices entitled, Claims Folder System, 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.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 1800-325-0778). 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.