SSA-1199-OP6 (Country) current

Form Approved OMB No. 0960-0686

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

Sign up now for
International Direct
Deposit. Your benefits
will be delivered safely
and on time!

Street, Apartment
City, Province,
Postal Code
Country

Name of Person Entitled to the Benefit

Social Security Claim Number: IMPORTANT

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.
SIGNATURE

YOUR DAYTIME TELEPHONE NUMBER

DATE

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

This account is:

□ My own account

□ A joint account

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

SIGNATURE OF
BANK OFFICIAL
Print the routing and account numbers for this account, or Print the IBAN.
Bank and Branch Routing Number
BANK PHONE NUMBER

Account Number
IBAN
Mail completed form to:

Form SSA-1199-XXXXX (2/2007)

Social Security Administration
Office of International Operations
PO Box 17769
Baltimore, MD 21235-7769
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
Social Security Administration
American Embassy in your country
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 (2/2007)

Please see below
for revised Privacy
Act and Paperwork
Reduction Act
statements.

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.