Form Ssa-1199-Fr - Direct Deposit Sign-Up Form (France)
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1
2Social Security Administration
Form Approved
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (France)
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
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.
Your Signature
Date
Signature
Date
This account is:
My own account
A joint account
SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
MAIL COMPLETED FORMS TO:
Social Security Administration
Office of International Operations
SOCIAL SECURITY ADMINISTRATION
PO Box 17769
Baltimore, MD 21235-7769
USA
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN EURO
Name of Bank
Bank Phone Number
(Nom de la banque)
(Numero de telephone de la banque)
Address of Bank
(Adresse de la banque)
Print Name of Bank Official
Signature of Bank Official
Bank Code
Branch Code
Account Number
(Code Banque)
(Code Guichet)
(Numero de Compte)
Form SSA-1199-FR (07/2012)
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