Form SSA-1199-CN (04-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
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:
Telephone Number:
SOCIAL SECURITY CLAIM NUMBER
B.I.C.
(OPTIONAL)
Name of Person Entitled to the Benefits
THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Type Amount
PAYEE CERTIFICATION
I (beneficiary or representative payee) certify that I have read
and understand the back of this form. In signing this form, I
authorize the Social Security Administration to send this
payment to the financial institution indicated in Section 3 and
deposit it in the designated account. I understand that personal
information in these payments is confidential, but I consent to
disclosure of payment information compelled by law or
necessary to protect against fraud or crime.
Your Signature Date
Are you the Representative Payee?
Yes No
Beneficiary Date of Birth
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.
Joint Account Holder's Signature Date
This account is:
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 Earnings and International Operations
Division of International Operations
PO Box 17769
Baltimore, MD 21235-7769
USA
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN Canadian Dollars or U.S. Dollars
NAME OF BANK BANK PHONE NUMBER
ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL SIGNATURE OF BANK OFFICIAL
Canadian Dollar: Checking Savings U.S. Dollar: Checking Savings
To have your benefits sent to a U.S. dollar account, have your bank complete section 3.A. or 3.B. To have your benefits
sent to a Canadian Dollar account, have your bank complete section 3.C.
A. U.S. dollar account at Royal Bank of
Canada:
RTN: 026004093
Transit Number:
(5 digits, begins with
zero)
Account Number:
(Must be 7
digits, begins
with 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:
ALL: No dashes, except Caisse Populaire 815 & 829 before 7th digit, 865 before 6th digit (which is always 2). POMS GN
02402.300
