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: B.I.C. (OPTIONAL) SOCIAL SECURITY CLAIM NUMBER Name of Person Entitled to the Benefits Telephone Number: THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable) Type PAYEE CERTIFICATION I (beneficiary or representative payee) certify th.
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