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
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
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:
_ _ _ _ _ _ _ _ _ _ _ _
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Direct Deposit Sign-up Form - Canada PDF

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