Form SSA-1199-(Country) Direct Deposit Sign-Up Form (Name of Country)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM AUSTRALIA (DRAFT)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
MONTHLY BENEFITS BY DIRECT DEPOSIT
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Complete Section 1 and “SIGN YOUR NAME.”
Ask your bank to complete Section 3.
Mail completed form back using address in Section 2

SECTION 1 (TO BE COMPLETED BY PAYEE)
Name and Complete Mailing Address [P.O. boxes not
accepted]:

- SOCIAL SECURITY CLAIM NUMBER -

Name of Person Entitled to the Benefits

THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE

AMOUNT

TELEPHONE NUMBER:

PAYEE CERTIFICATION
I (beneficiary or representative payee) certify that I have read
and understand the back of this form. In signing this form, I
authorize the Social Security Administration to send this
payment to the financial institution indicated in Section 3 and
deposit it in the designated account. I understand that personal
information in these payments is confidential, but I consent to
disclosure of payment information compelled by law or
necessary to protect against fraud or crime.
YOUR SIGNATURE
DATE

ARE YOU THE REPRESENTATIVE PAYEE? YES

NO

JOINT ACCOUNT HOLDER’S CERTIFICATION (optional)
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

Beneficiary Date of Birth

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
SOCIAL SECURITY ADMINISTRATION

MAIL COMPLETED FORMS TO:
Federal Benefits Unit
U.S. Embassy
91 Vasilisis Sophias Avenue
101 60 Athens
Greece

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN AUSTRALIAN DOLLARS

NAME OF BANK

BANK PHONE NUMBER

ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL
BSB NUMBER

----Form SSA-1199-OP3 (7/2010)

SIGNATURE OF BANK OFFICIAL
ACCOUNT NUMBER

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 Australian bank account.

WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
You will receive your payment through Australian banking system and will usually be in your bank account shortly after
the regular payment date. With direct deposit, you will have immediate access to your money. This is the safest way of
receiving your benefits.

INFORMATION ABOUT CURRENCY CONVERSION:
With direct deposit, your U.S. Social Security payment is automatically converted to Australian Dollars (if applicable) at the
daily international exchange rate before deposited to your account.

**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 Social Security Administration or the Federal Benefits Unit in your area. You
must return to Social Security any payments deposited into a joint account after the death of a beneficiary.

IF YOUR ADDRESS CHANGES:
If your address changes, you must inform the Federal Benefits Unit or the Social Security Administration. Your
payments may stop if the Social Security Administration needs to contact you and cannot find your location.

CHANGING BANKS OR BANK ACCOUNTS
If you change your bank or your account, you must notify one of these offices:
Federal Benefits Unit
U.S. Embassy
91 Vasilisis Sophias Avenue
101 60 Athens
Greece

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

You may need to fill out a new Direct Deposit sign-up form. Do not close your old account until payments
have started coming to your new account.

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 1-800-325-0778). 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.
Form SSA-1199-OP3 (7/2010)

Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent you from
receiving benefit payments through foreign financial institutions.
We will use the information you provide to process benefit payments with your financial institution. We may
also share your information for the following purposes, called routine uses:
1. To the Department of State and its agents for administering the Act in foreign countries through
facilities and services of that agency; and
2. To third party contacts where necessary to establish or verify information provided by representative
payees or payee applicants.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in which
our records are compared with other records to establish or verify a person’s eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089,
entitled Claims Folders Systems and 60-0090, entitled Master Beneficiary Record. Additional information and
a full listing of all our SORNs are available on our website at https://www.ssa.gov/privacy.