International Direct Deposit Form

International Direct Deposit Enrollment
Sign-Up Form C. Bank Information
NAME OF BANK:
BANK PHONE NUMBER:

Directions
ADDRESS:
Please refer to the information on the reverse side before
completing this form.
You must complete a separate form for each type of COUNTRY:
federal payment (social security, supplemental income,
BANK CODE:
veterans benefits, etc.).
You are responsible for keeping the paying agency BRANCH CODE: (if necessary)
informed of any name or address changes.
ACCOUNT NUMBER OR IBAN
THIS ACCOUNT IS:

MY OWN ACCOUNT A JOINT ACCOUNT
A. Person to Receive Payment THIS ACCOUNT IS:

CHECKING SAVINGS
NAME: THIS ACCOUNT IS:

Last First Middle initial US DOLLAR ACCOUNT LOCAL CURRENCY
NAME OF PERSON ENTITLED TO PAYMENT: PRINT NAME OF BANK OFFICIAL:
(if different from above)
SIGNATURE OF BANK OFFICIAL:
ADDRESS:
DATE:
TELEPHONE NUMBER:
D. Certification
SOCIAL SECURITY NUMBER OR
FEDERAL TAX ID NUMBER: I certify that I am entitled to receive the payment identified above, and that
I have read and understand the back of this form. In signing this form, I
authorize this payment to be sent to the financial institution named in Part
C above, to be deposited into the account above.
Signature Date
B. Type of Payment (check only one)
SOCIAL SECURITY CIVIL SERVICE RETIREMENT
SUPPLEMENTAL SECURITY VA COMPENSATION

E. For Joint Account Holders
INCOME OR PENSION
I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT
HOLDERS on the back of this form.
RAILROAD RETIREMENT MILITARY ACTIVE
Name (print)
MILITARY RETIRED MILITARY ANNUITANT
Signature Date
OTHER (Specify)
Optional Form 1199-I
(June 2005)
PLEASE READ THIS CAREFULLY
PRIVACY ACT NOTICE IF YOUR ADDRESS CHANGES

Your social security number and the other informa- If your address changes, you must inform the U.S.
tion requested will allow the federal government to government agency that issued the payment. If the
make payments to you by electronic funds transfer. agency needs to contact you and cannot locate you,
This collection of information is authorized by Title your payment may be stopped.
31 of the United States Code, Section 3332(g). Also,
Executive Order 9397, November 22, 1943, author-
CHANGING BANKS OR BANK ACCOUNTS
izes the use of your social security number. Your
social security number is requested to ensure the If you change your bank or your account number,
accurate identification and retention of records you must notify the U.S. government agency that
pertaining to you and to distinguish you from other issues your payments.
federal recipients.
You may need to fill out a new sign-up form. Do not
This information will be disclosed to the Department close your old account until payments have started
of the Treasury or another disbursing official to coming to your new account.
process federal payments to you by electronic funds
transfer. This information may also be disclosed to a BURDEN ESTIMATE STATEMENT
court, congressional committee or another govern- The estimated average burden associated with this
ment agency as authorized or required by federal collection of information is 10 minutes per respon-
law and your financial institution to verify receipt of dent or record keeper, depending on the individual
your federal payments. Although providing the circumstances. Comments concerning the accuracy
requested information is voluntary, a federal law of this burden estimate and suggestions for
may require that you receive your federal payments reducing this burden should be directed to the
by electronic funds transfer. If so, failure to provide Financial Management Services, Facilities
any part of the requested information may delay or Management Division, Administrative Programs
prevent the federal government from making Division, Records and Information Management
payments to you. Program, 3700 East-West Highway, Hyattsville, MD
20782. This address should only be used for
SPECIAL NOTICE TO JOINT ACCOUNT comments and/or suggestions concerning the
HOLDERS amount of time spent to collect the data. Do not
If your receiving bank and issuing agency allow a send the completed paperwork to the address
joint account with a person who receives U.S. gov- above for processing.
ernment issued payment(s) and that person dies,
you must immediately contact your bank and the
American Embassy/Consulate in your country
and/or the U.S. government agency that issued the
payment. Any U.S. government payment deposited
into a joint account after the death of a recipient
must be returned to the agency that issued the
payment.

International Direct Deposit Form

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International Direct Deposit Form

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International Direct Deposit Enrollment

Sign-Up Form C. Bank Information

BANK PHONE NUMBER:

THIS ACCOUNT IS:

A. Person to Receive Payment THIS ACCOUNT IS:

NAME: THIS ACCOUNT IS:

SOCIAL SECURITY CIVIL SERVICE RETIREMENT

SUPPLEMENTAL SECURITY VA COMPENSATION

PRIVACY ACT NOTICE IF YOUR ADDRESS CHANGES

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