Direct Deposit Enrollment Form

OMB No. 0960-0711

(Date)

Dear Social Security Recipient:

(Name of Financial Institution) is taking this opportunity to explain the advantages of having your monthly benefits payments deposited directly into your bank account. There are many advantages that the direct deposit of your Social Security check offers to you. With direct deposit of your Social Security check:

• You can count on your benefits arriving on time every month.

• It is safe, secure and convenient.

• It costs you nothing, yet saves the government about 62 cents per check.

We have made it easy for you to sign up –

Simply review the information provided on the attached form about your bank account and Social Security benefits sign the form and return it in the enclosed postage-free envelope. Forms received by Social Security before the fifteenth day of the month will usually be processed so that your next month’s check is deposited into your account, ready for instant access, on the day your payment is due. You will receive a confirmation letter from Social Security when the Direct Deposit is processed.

We have already embedded the information about your Social Security benefit and your account at (Name of Institution) in the secure bar code on the attached form. To protect your privacy, we have only shown the last four digits of your account information and Social Security claim number to assist you in verifying the information provided. If you prefer to have your benefits deposited to another account or you have questions about Direct Deposit and your Social Security benefits, you can call 1-800-772-1213 or visit the Social Security website at: www.socialsecurity.gov

Once you sign and return this form, you will never have to worry about your Social Security benefit being delayed or stolen again. Don’t delay – sign up for Direct Deposit today. Simply check YES on the attached form, sign it and return within 30 days.

Sincerely,

(Signature of Bank Official)

(Title of Bank Official)

Complete this easy form and we’ll take care of the rest!

COMPLETE THIS EASY FORM AND WE’LL TAKE CARE OF THE REST!

About the Information Being Released - By submitting this form, I understand that I am authorizing the release of my financial information as displayed on this form to the Social Security Administration (SSA) to use to begin direct deposit of my Social Security benefits. As a courtesy to me, I understand that my financial institution has encoded my financial information in the barcode printed at the bottom to facilitate SSA establishing direct deposit for me. I understand that I am releasing to SSA my financial account information, including the type of account, the account title, the account number, a claim and unit number, and a routing and transit number necessary to set up the direct deposit process. I understand that all of the information I am providing to SSA is protected under the Privacy Act of 1974. Further information regarding how SSA collects, maintains, uses, and discloses information protected by the Privacy Act may be obtained in any SSA office, or on SSA’s website, http://www.socialsecurity.gov/foia/bluebook/bluebook.htm. I further understand that I can choose to cancel direct deposit of my Social Security benefits at any time, through the assistance of my local Social Security office or by calling 1-800-772-1213 and that my benefits will not be adversely affected in any way if I choose to do so.

_______________________________________________________________________

P

FOR SSA USE ONLY

aperwork 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 2 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. Send only comments relating to our time estimate to this address, not the completed form.

DO NOT CUT

Mr. Sample A. Sample Social Security Number: XXX-XX-1111

Address 1 Social Security Claim Number: XXX-XX-2222NN

Address 2 Type of Account: Checking/Savings (FI to choose one)

City, ST 12345 Account Number: XXXXXXXXXXXXX3333

Yes. Deposit my Social Security payment to the bank account listed above.

Sign here: _______________________ Daytime Phone Number: ____________

SEND THIS COMPLETED FORM TO: Wilkes-Barre Data Operations Center, P O Box XXX, Wilkes-Barre, PA XXXXX within 30 days.

If you want to have your Social Security payment sent to a different bank account, you can call 1-800-772-1213 or visit the Social Security website at: www.socialsecurity.gov

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