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Get SSA-1199-CN 2020-2021

POMS GN 02402. 300. Form SSA-1199-CN 08/2010 IMPORTANT INFORMATION - PLEASE READ CAREFULLY The Information you give on this form is confidential. We need the information in order to send your monthly benefits directly into your account at the financial institution in Canada. With Direct Deposit you will have immediate access to your money. Direct Deposit is the safest way of receiving your benefits. However delays in direct deposit can occur when a payment date falls on a holiday in the country of the receiving bank. HOW TO SIGN UP 1 On the other side of this form complete Sections 1 and 3. Remember to sign your name. Social Security Administration Form Approved OMB No* 0960-0686 DIRECT DEPOSIT SIGN-UP FORM Canada 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 - SOCIAL SECURITY CLAIM NUMBER - Name of Person Entitled to the Benefits Telephone Number Type PAYEE CERTIFICATION JOINT ACCOUNT HOLDER S CERTIFICATION optional 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. Date Your Signature THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY if applicable Amount SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS* This account is My own account A joint account SECTION 2 MAILING ADDRESS GOVERNMENT AGENCY NAME MAIL COMPLETED FORMS TO Office of International Operations PO Box 17769 Baltimore MD 21235-7769 Name of Bank Bank Phone Number Address of Bank Print Name of Bank Official Canadian Dollar Signature of Bank Official Checking A U*S* dollar account at Royal Bank of Canada RTN 026004093 Transit Number 5 Digits begins with a zero Account Number Must be 7 digits begins with a 4 or 8 no dash Savings U*S* Dollar institution in Canada RTN 62 in Canada RTN 51 Institution Number ALL NO dashes except Caisse Populair 815 829 before 7th digit 865 before 6th digit which is always 2. POMS GN 02402. 300. Form SSA-1199-CN 08/2010 IMPORTANT INFORMATION - PLEASE READ CAREFULLY The Information you give on this form is confidential* We need the information in order to send your monthly benefits directly into your account at the financial institution in Canada* With Direct Deposit you will have immediate access to your money. Direct Deposit is the safest way of receiving your benefits. However delays in direct deposit can occur when a payment date falls on a holiday in the country of the receiving bank. HOW TO SIGN UP 1 On the other side of this form complete Sections 1 and 3. Remember to sign your name..

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