SSA-1199-OP6 Direct Deposit Sign-Up Form (Name of Country)

SECTION 1 (TO BE COMPLETED BY PAYEE)

Form Approved OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (NAME OF COUNTRY)

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

Name and Complete Mailing Address:

- SOCIAL SECURITY CLAIM NUMBER -

Name of Person Entitled to the Benefits

TELEPHONE NUMBER:

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

TYPE

AMOUNT

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.

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

DATE

SIGNATURE

DATE

This account is: My own account A joint account

SECTION 2 (MAILING ADDRESS)

GOVERNMENT AGENCY NAME: SOCIAL SECURITY ADMINISTRATION

MAIL COMPLETED FORMS TO: ADDRESS OF EMBASSY FOR THAT COUNTRY

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)

THIS ACCOUNT MUST BE IN EUROS

NAME OF BANK

BANK PHONE NUMBER

ADDRESS OF BANK

PRINT NAME OF BANK OFFICIAL

SIGNATURE OF BANK OFFICIAL

Bank Code

Account Number

IBAN

Form SSA-1199-OP6 (7/2010)