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

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Form Approved OMB No. 0960-0686
Form SSA-1199-OPXX (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

DIRECT DEPOSIT SIGN-UP FORM (SAMPLE)
APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY
MONTHLY BENEFITS BY DIRECT DEPOSIT




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:

BIC
(OPTIONAL)

- SOCIAL SECURITY CLAIM NUMBER -

Name of Person Entitled to the Benefits
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE

TELEPHONE NUMBER:

AMOUNT

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.

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.

YOUR SIGNATURE

JOINT ACCOUNT HOLDER’S SIGNATURE

DATE

ARE YOU THE REPRESENTATIVE PAYEE? Yes

No

This account is:
My own account

DATE

A joint account

BENEFICIARY DATE OF BIRTH

SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:

MAIL COMPLETED FORMS TO:

SOCIAL SECURITY ADMINISTRATION

[Return Address]

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN [Currency]

NAME OF BANK
ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL

BANK PHONE NUMBER
SIGNATURE OF BANK OFFICIAL

Type of Depositor Account

Checking

Savings

Account Number

Bank Identification Code

Bank Number/Code

Bank Sorting Code

Beneficiary ID

Beneficiary National ID

Branch Number/Code

Canadian Account Number

Check Digit Code

China National Advanced
Payment System (CNAPS)

Codigo de Cuenta
Interbancario (CCI) Code

Computerized National
Identity Card (CNIC) number

Control Code

Country Bank Information

Country Code

Debit Card Number

Institution Code

International Bank Account
Number (IBAN)

Korean Registration Number

Locality

Deposit Account Number
(DAN)
Mexican Bank Association
(ABM) number

Paraguay Bank National ID

Passport ID

Reasons for payment check
boxes

Relevé d'Identité Bancaire
(RIB)

Routing and Transit Number
(RTN)

Smart National Identity Card
(SNIC) number

Society for Worldwide
Interbank Financial
Telecommunication- Business
Identifier Code (SWIFT-BIC)

State ID

Tax ID number

Tax National ID

Form SSA-1199-OPXX (XX/XXXX)

Bank State Branch
Number/Code
Check Char (CIN)

National Identity Document

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Form SSA-1199-OPXX (X/XXXX)

_____________________________________________________________________
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 [Country] bank account.
WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
You will receive your payment through the [Country] 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 [Currency] (if applicable) at
the daily international exchange rate before being 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:

[Return Address]

Social Security Administration
Office of Earnings 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.

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Form SSA-1199-OPXX (X/XXXX)

_______________________________________________________________________________________
Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Statement
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.

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.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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:
•

To the Department of State and its agents for administering the Act in foreign
countries through facilities and services of that agency; and

•

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, as published in the Federal Register (FR) on
April 1, 2003 at 68 FR 15784, and 60-0090, entitled Master Beneficiary Record, as published on
FR January 11, 2006 at 71 FR 1826. Additional information and a full listing of all our SORNs
are available on our website at https://www.ssa.gov/privacy.