Direct Deposit Sign-Up Form printable pdf download

Form Approved OMB No. 0686-0686

DIRECT DEPOSIT SIGN-UP FORM (ISRAEL)

APPLICATION FOR PAYMENT OF UNITED STATES SOCIAL SECURITY

MONTHLY BENEFITS BY DIRECT DEPOSIT

•

If your name in Section 1 does not match the name on your bank account, please add this name to your bank account.

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Complete Sections 1, 2 & 3. **SIGN YOUR NAME in Section 3.**

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Ask your bank to complete Section 4. Include a voided check if available, to help us code your direct deposit.

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Mail the completed form to an office below.

SECTION 1

SECTION 2

Name and Complete Mailing Address:

Name of Bank or Other Financial Institution:

Address of Financial Institution:

The type of account is:

___Checking

___Savings

Social Security Claim Number – IMPORTANT:

The account is:

___ Only my account

___ A joint account

SECTION 3

PAYEE CERTIFICATION

JOINT ACCOUNT HOLDER’S CERTIFICATION

I certify that I have read and understand the back of this form. In signing

I certify that I have read and understand the back of this form, including the

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.

SIGNATURE

DATE

SIGNATURE

DATE

YOUR DAYTIME TELEPHONE NUMBER

SECTION 4 (Ask your bank to complete this section.) This must be a Shekel account.

NAME OF BANK

ADDRESS OF BANK

BANK PHONE NUMBER

BANK & BRANCH CODE

BANK CODE

BRANCH CODE

ACCOUNT

NUMBER

BANK OFFICIAL'S NAME

SIGNATURE OF

PLEASE PRINT

BANK OFFICIAL

Mail the completed form to one of the following:

American Embassy

American Consulate General

Federal Benefits Unit

PO Box 290

71 Hayarkon Street

18 Agron Road

Jerusalem Israel 91002

Tel Aviv Israel 63903

Jerusalem Israel 94190

Form SSA-1199-OP14 (07/2007)

Direct Deposit Sign-Up Form

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