Form Ssa-1199-Po-Op1 - Direct Deposit Sign-Up Form (Poland)
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3Form Approved
Social Security Administration
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (Poland)
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
Name of Person Entitled to the Benefits
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Telephone Number:
Type
Amount
PAYEE CERTIFICATION
JOINT ACCOUNT HOLDER'S CERTIFICATION (optional)
I certify that I have read and understand the back of this
I certify that I have read and understand the back of this
form. In signing this form, I authorize the Social Security
form, including the SPECIAL NOTICE TO JOINT
Administration to send my payment to my bank and deposit
ACCOUNT HOLDERS.
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:
Required: Date of Birth
My own account
A joint account
Month/Day/Year
SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
MAIL COMPLETED FORMS TO:
American Embassy
Federal Benefits Unit
SOCIAL SECURITY ADMINISTRATION
ul. Piekna 12
00-539 Warszawa
Poland
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN U.S. DOLLARS
Bank Phone Number
Name of Bank
Address of Bank
Print Name of Bank Official
Signature of Bank Official
Poland
2 Check
Bank-Branch Code
Account Number
Code
Digits
(Must have all 8 digits)
(Must have all 16 digits)
Form SSA-1199-PO-OP1 (09-2015)
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