1
2International 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.
COUNTRY:
You must complete a separate form for each type of
federal payment (social security, supplemental income,
BANK CODE:
veterans benefits, etc.).
BRANCH CODE: (if necessary)
You are responsible for keeping the paying agency
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
I certify that I am entitled to receive the payment identified above, and that
FEDERAL TAX ID NUMBER:
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
E. For Joint Account Holders
SUPPLEMENTAL SECURITY
VA COMPENSATION
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)
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.
COUNTRY:
You must complete a separate form for each type of
federal payment (social security, supplemental income,
BANK CODE:
veterans benefits, etc.).
BRANCH CODE: (if necessary)
You are responsible for keeping the paying agency
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
I certify that I am entitled to receive the payment identified above, and that
FEDERAL TAX ID NUMBER:
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
E. For Joint Account Holders
SUPPLEMENTAL SECURITY
VA COMPENSATION
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
If you change your bank or your account number,
social security number is requested to ensure the
you must notify the U.S. government agency that
accurate identification and retention of records
issues your payments.
pertaining to you and to distinguish you from other
federal recipients.
You may need to fill out a new sign-up form. Do not
close your old account until payments have started
This information will be disclosed to the Department
coming to your new account.
of the Treasury or another disbursing official to
process federal payments to you by electronic funds
BURDEN ESTIMATE STATEMENT
transfer. This information may also be disclosed to a
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
send the completed paperwork to the address
If your receiving bank and issuing agency allow a
above for processing.
joint account with a person who receives U.S. gov-
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.
