Direct Deposit Sign-Up Form (South Korea)
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1
2
3Social Security Administration
Form Approved
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (South Korea)
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
B.I.C
Name of Person Entitled to the Benefits
Telephone Number:
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Type
Amount
PAYEE CERTIFICATION
JOINT ACCOUNT HOLDER'S CERTIFICATION (optional)
I certify that I have read and understand the back of this form.
I certify that I have read and understand the back of this form, including the
In signing this form, I authorize the Social Security Administration to send my
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
payment to my bank and deposit it in the designated account. I understand
Signature
Date
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.
This account is:
Your Signature
Date
My own account
A joint account
Are you the Representative Payee?
Yes
No
Beneficiary Date of Birth
SECTION 2 (MAILING ADDRESS)
MAIL COMPLETED FORMS TO:
GOVERNMENT AGENCY NAME:
Social Security Administration U.S. Embassy Manila
1201 Roxas Boulevard
SOCIAL SECURITY ADMINISTRATION
Ermita, Manila
0930 Philippines
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN SOUTH KOREAN WON
Name of Bank
Bank Phone Number
Address of Bank
Print Name of Bank Official
Signature of Bank Official
-
S. Korean National Pension Number
Account Type
Checking
Savings
Account Number
Print the entire SWIFT/BIC code in the blocks below.
Form SSA-1199-OP39 (09-2014)
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