Direct Deposit Sign-Up Form (Germany) - Social Security
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1
2
3Social Security Administration
Form Approved
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (Germany)
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
B.I.C
Name of Person Entitled to the Benefits
Telephone Number:
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Type
Amount
PAYEE CERTIFICATION
JOINT ACCOUNT HOLDER'S CERTIFICATION (optional)
I certify that I have read and understand the back of this form.
I certify that I have read and understand the back of this form, including the
In signing 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.
Your Signature
Date
Signature
Date
Are you the Representative Payee?
This account is:
Yes
No
My own account
A joint account
Beneficiary Date of Birth
SECTION 2 (MAILING ADDRESS)
GOVERNMENT AGENCY NAME:
MAIL COMPLETED FORMS TO:
AMERICAN CONSULATE GENERAL
FEDERAL BENEFITS UNIT
SOCIAL SECURITY ADMINISTRATION
GIESSENER STRASSE 30
60435 FRANKFURT am MAIN
GERMANY
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN EUROS
Name of Bank
Bank Phone Number
Address of Bank
Print Name of Bank Official
Signature of Bank Official
Type of Depositor Account
Checking
Savings
Print the entire SWIFT/BIC code in the blocks
Print the IBAN number in the blocks below. Fill all blocks.
below.
Form SSA-1199-GE (05-2014)
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