Fillable Printable Direct Deposit Sign-up Form - Canada
Fillable Printable Direct Deposit Sign-up Form - Canada
Direct Deposit Sign-up Form - Canada
This account is:
Social Security Administration
Form Approved
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (Canada)
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
Telephone Number:
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Type
Amount
PAYEE CERTIFICATION
I certify that I have read and understand the back of this form.
In signing this form, I authorize the Social Security Administration to send my
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.
JOINT ACCOUNT HOLDER'S CERTIFICATION (optional)
I certify that I have read and understand the back of this form, including the
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
Your Signature
Date
My own account
A joint account
SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
SOCIAL SECURITY ADMINISTRATION
MAIL COMPLETED FORMS TO:
Social Security Administration
Office of International Operations
PO Box 17769
Baltimore, MD 21235-7769
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
Name of Bank
Bank Phone Number
Address of Bank
Print Name of Bank Official
Signature of Bank Official
Form SSA-1199-CN (08/2010)
Signature
Date
Savings
Checking
Savings
Checking
Canadian Dollar:
U.S. Dollar:
ALL: NO dashes, except Caisse Populair 815 & 829 before 7th digit, 865 before 6th digit (which is always 2). POMS GN 02402.300.
A) U.S. dollar account at Royal Bank of Canada
RTN: 026004093
Transit Number:
_ _ _ _ _ (5 Digits, begins with a zero)
Account Number:
_ _ _ _ _ _ _ (Must be 7 digits, begins with a 4 or
8, no dash)
B) U.S. dollar account at any other financial
institution in Canada
RTN: 62
Transit Number:
_ _ _ _ _
Institution Number:
_ _ _
Account Number:
_ _ _ _ _ _ _ _ _ _ _ _
C) Canadian dollar account at any financial institution
in Canada
RTN: 51
Transit Number:
_ _ _ _ _
Institution Number:
_ _ _
Account Number:
_ _ _ _ _ _ _ _ _ _ _ _
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
The Information you give on this form is confidential. We need the information in order to send your monthly benefits directly
into your account at the financial institution in Canada. With Direct Deposit, you will have immediate access to your money.
Direct Deposit is the safest way of receiving your benefits. However, delays in direct deposit can occur when a payment date
falls on a holiday in the country of the receiving bank.
HOW TO SIGN UP:
**SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS**
If you have a joint account with a person who receives Social Security payments, and that person dies, you must immediately
contact your bank and the Social Security Administration or the American Embassy or Consulate in your area. Any Social
Security payments deposited into a joint account after the death of a beneficiary must be returned to Social Security.
CHANGING BANKS OR BANK ACCOUNTS:
If you change your bank or your account, you must notify us by going to the nearest Social Security office or by contacting the
following office below.
Social Security Administration
Office of International Operations
PO Box 17769
Baltimore, MD 21235-7769
USA
You may needs to fill out a new International Direct Deposit sign-up form. Do not close your old account until
payments have started coming to your new account.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. ยง 3507, as amended
by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are
also listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
Form SSA-1199-CN (08/2010)
Social Security benefits can be directly deposited in either your Canadian dollar account or your
U.S. dollar account in Canada
1: On the other side of this form, complete Sections 1 and 3. Remember to sign your name.
2: If you want your benefits sent to your U.S. dollar account, ask your bank to complete Section 3.A or 3.B.
3: If you want your benefits sent to your Canadian dollar account, ask your bank to complete Section 3.C
4: Mail the completed form in the envelope provided. Include a voided check, if possible.
INFORMATION ABOUT CURRENCY CONVERSION:
With Direct Deposit, your U.S. Social Security payment is automatically converted (if applicable) to the currency of the country
in which your account is in at a good exchange rate a few days before your payment date.
