Fillable International Direct Deposit Enrollment Form printable pdf download

International Direct Deposit Enrollment Form

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International Direct Deposit Enrollment

Sign-Up Form

C. Bank Information

NAME OF BANK:

BANK PHONE NUMBER:

Directions

ADDRESS:

Please refer to the information on the reverse side before

completing this form.

COUNTRY:

You must complete a separate form for each type of

federal payment (social security, supplemental income,

BANK CODE:

veterans benefits, etc.).

BRANCH CODE: (if necessary)

You are responsible for keeping the paying agency

informed of any name or address changes.

ACCOUNT NUMBER OR IBAN

THIS ACCOUNT IS:

MY OWN ACCOUNT

A JOINT ACCOUNT

A. Person to Receive Payment

THIS ACCOUNT IS:

CHECKING

SAVINGS

NAME:

THIS ACCOUNT IS:

Last

First

Middle initial

US DOLLAR ACCOUNT

LOCAL CURRENCY

NAME OF PERSON ENTITLED TO PAYMENT:

PRINT NAME OF BANK OFFICIAL:

(if different from above)

SIGNATURE OF BANK OFFICIAL:

ADDRESS:

DATE:

TELEPHONE NUMBER:

D. Certification

SOCIAL SECURITY NUMBER OR

I certify that I am entitled to receive the payment identified above, and that

FEDERAL TAX ID NUMBER:

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

authorize this payment to be sent to the financial institution named in Part

C above, to be deposited into the account above.

Signature

Date

B. Type of Payment (check only one)

SOCIAL SECURITY

CIVIL SERVICE RETIREMENT

E. For Joint Account Holders

SUPPLEMENTAL SECURITY

VA COMPENSATION

INCOME

OR PENSION

I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT

HOLDERS on the back of this form.

RAILROAD RETIREMENT

MILITARY ACTIVE

Name (print)

MILITARY RETIRED

MILITARY ANNUITANT

Signature

Date

OTHER (Specify)

Optional Form 1199-I

(June 2005)

International Direct Deposit Enrollment Form

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