Fillable Social Security Direct Deposit Sign Up Form (Page 2 of 2) in pdf

PLEASE READ THIS CAREFULLY

PRIVACY ACT NOTICE

Your social security number and the other information requested will allow the federal government to make

payments to you by Direct Deposit. This collection of information is authorized by Title 31 of the United States

Code, Section 3332(g). Also, Executive Order 9397, November 22, 1943, authorizes the use of your social

security number. Your social security number is requested to ensure the accurate identification and retention

of records pertaining to you and to distinguish you from other recipients of federal payments.

This information will be disclosed to the Department of the Treasury or another disbursing official to process

federal payments to you by Direct Deposit. This information may also be disclosed to a court, congressional

committee or another government agency as authorized or required by federal law and to your financial

institution to verify receipt of your federal payments. Although providing the requested information is

voluntary, your Direct Deposit payment may be delayed or Treasury may be unable to send it if you fail to

provide the information.

SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS

If your account is a joint account and receives Direct Deposit benefit payments, you must inform the federal

agency and the financial institution of the death of a beneficiary. Payments sent by Direct Deposit after the

date of death or ineligibility of a beneficiary (except for salary payments) must be returned to the federal

agency. The federal agency will then determine if the survivor is eligible for benefits.

CANCELLATION

Your payment will be sent by Direct Deposit until the federal agency that issues the payments is notified to cancel,

such as in the case of death or legal incapacity of the payment recipient.

Your financial institution may cancel your Direct Deposit authorization. Your financial institution is required to

give you written notice 30 days in advance of the cancellation date. If this occurs, you must notify the federal

agency that the Direct Deposit authorization was cancelled.

(NOTE: If you are initiating direct deposit to a savings account

you may need to contact your bank for the correct routing and account numbers.)

BURDEN ESTIMATE STATEMENT

The estimated average time (burden hours) associated with filling out this paperwork is 10 minutes per respondent or recordkeeper,

depending on individual circumstances. Comments concerning the accuracy of this time estimate and suggestions for reducing the

burden should be directed to the Financial Management Service, Administrative Programs Division, Records and Information

Management Program, 3700 East-West Highway, Room 135, Hyattsville, MD 20782. THIS ADDRESS SHOULD ONLY BE USED

FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT COLLECTING THE DATA. DO NOT

SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.

Social Security Direct Deposit Sign Up Form Page 2