Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 6

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SECTION V: Your Information When You Are Working for a Firm or Organization
Complete this section if your work as a representative will be affiliated with a firm or organization. If you work for more than one
firm or organization complete and attach as many copies of this section as needed. You will need an EIN in order to complete
this section.
Complete 1 through 5 below.
1.
Employer Identification Number (EIN)
(See your W-2 or contact the firm or organization to get this number.)
Name of Firm or Organization
Same as home address in Section I
2.
Your Address for Receipt of Notices
Same as notice address in Section IV
Street Line 1
Line 2
City
State
ZIP/Postal Code
Country (if outside the U.S.)
Business Telephone Number
Business Fax Number
3.
(Optional)
Same as home number in Section I
Same as business number in Section IV
Country/Area Code
Phone Number
Extension
Country/Area Code
Fax Number
4.
Business Email Address
(Optional)
5.
What is your preferred payment method?
Direct Deposit to U.S. Bank
Same bank information as provided in Section IV
OR
Direct deposit to the account shown below. I am the owner or co-owner of this account. (You must be the
owner or co-owner of the account)
Checking
Type of Financial Account:
Savings
Routing Number
Account Number
OR
Check – Will be mailed to the Notice Address
Form SSA-1699 (09-2013)
4

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