Fillable Ssa 1199 Op23 SSA 1199 OP23 (Social Security Administration)

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Ssa 1199 Op23 SSA 1199 OP23 (Social Security Administration)

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Form SSA-1199-OP23 (10-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0686
DIRECT DEPOSIT SIGN-UP FORM (Saint Kitts and Nevis)
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:
Federal Benefits Unit
U.S. Embassy
Av. Republica de Colombia #57
Santo Domingo
Dominican Republic
SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)
THIS ACCOUNT MUST BE IN EAST CARIBBEAN DOLLARS
NAME OF BANK
BANK PHONE NUMBER
ADDRESS OF BANK
PRINT NAME OF BANK OFFICIAL SIGNATURE OF BANK OFFICIAL
Type of Depositor Account
Checking Savings
Bank Code Branch Code
Account Number
Form SSA-1199-OP23 (10-2019) Page 2 of 3
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
The information you give on this form is confidential. We need the information to send your U.S. Social Security payments
electronically to your Saint Kitts & Nevis bank account.
WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS
You will receive your payment through the Saint Kitts & Nevis banking system and will usually be in your bank account shortly
after the regular payment date. With direct deposit, you will have immediate access to your money. This is the safest way of
receiving your benefits.
INFORMATION ABOUT CURRENCY CONVERSION:
With direct deposit, your U.S. Social Security payment is automatically converted to East Caribbean Dollars (if applicable) at
the daily international exchange rate before being deposited to your account.
**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 Federal Benefits Unit in your area. You must return to Social
Security any payments deposited into a joint account after the death of a beneficiary.
IF YOUR ADDRESS CHANGES:
If your address changes, you must inform the Federal Benefits Unit or the Social Security Administration. Your
payments may stop if the Social Security Administration needs to contact you and cannot find your location.
CHANGING BANKS OR BANK ACCOUNTS:
If you change your bank or your account, you must notify one of the following offices:
Federal Benefits Unit
U.S. Embassy
Av. Republica de Colombia #57
Santo Domingo
Dominican Republic
Social Security Administration
Office of Earnings and International Operations
Division Of International Operations
PO Box 17769
Baltimore, MD
21235-7769
USA
You may need to fill out a new Direct Deposit sign-up form.
Do not close your old account until payments have started coming to your new account.
Form SSA-1199-OP23 (10-2019) Page 3 of 3
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent you from receiving benefit payments through
foreign financial institutions.
We will use the information you provide to process benefit payments with your financial institution. We may also share your
information for the following purposes, called routine uses:
• To the Department of State and its agents for administering the Act in foreign countries through facilities and
services of that agency; and
• To third party contacts where necessary to establish or verify information provided by representative payees or
payee applicants.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims
Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0090, entitled Master
Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional information and a full listing of all our
SORNs are available on our website at https://www.ssa.gov/privacy
.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 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.
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Completed 22 July 2020

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