Optional Form 1199i, International Direct Deposit Enrollment, June

International Direct Deposit Enrollment

Directions

Please refer to the information on the reverse side before

completing this form.

You must complete a separate form for each type of

federal payment (social security, supplemental income,

veterans benefits, etc.).

You are responsible for keeping the paying agency

informed of any name or address changes.

NAME:

Last First Middle initial

NAME OF PERSON ENTITLED TO PAYMENT:

(if different from above)

ADDRESS:

TELEPHONE NUMBER:

SOCIAL SECURITY NUMBER OR

FEDERAL TAX ID NUMBER:

A. Person to Receive Payment

NAME OF BANK:

BANK PHONE NUMBER:

ADDRESS:

COUNTRY:

BANK CODE:

BRANCH CODE: (if necessary)

ACCOUNT NUMBER OR IBAN

THIS ACCOUNT IS:

MY OWN ACCOUNT A JOINT ACCOUNT

THIS ACCOUNT IS:

CHECKING SAVINGS

THIS ACCOUNT IS:

US DOLLAR ACCOUNT LOCAL CURRENCY

PRINT NAME OF BANK OFFICIAL:

SIGNATURE OF BANK OFFICIAL:

DATE:

C. Bank Information

SOCIAL SECURITY CIVIL SERVICE RETIREMENT

SUPPLEMENTAL SECURITY VA COMPENSATION

INCOME OR PENSION

RAILROAD RETIREMENT MILITARY ACTIVE

MILITARY RETIRED MILITARY ANNUITANT

OTHER (Specify)

B.Type of Payment (check only one)

I certify that I am entitled to receive the payment identified above, and that

I have read and understand the back of this form. In signing this form, I

authorize this payment to be sent to the financial institution named in Part

C above, to be deposited into the account above.

Signature Date

D. Certification

I certify that I have read the SPECIAL NOTICE TO JOINT ACCOUNT

HOLDERS on the back of this form.

Name (print)

Signature Date

E. For Joint Account Holders

Optional Form 1199-I

(June 2005)

Sign-Up Form

PRIVACY ACT NOTICE

Your social security number and the other informa-

tion requested will allow the f

ederal government to

make payments to you by electronic funds transfer.

This collection of information is authorized by Title

31 of the United States Code, Section 3332(g). Also,

Executive Order 9397, November 22, 1943, author-

izes the use of your social security number.Your

social security number is requested to ensure the

accurate identification and retention of records

pertaining to you and to distinguish you from other

federal recipients.

This information will be disclosed to the Department

of the Treasury or another disbursing official to

process federal payments to you by electronic funds

transfer. This information may also be disclosed to a

court, congressional committee or another govern-

ment agency as authorized or required by federal

law and your financial institution to verify receipt of

your federal payments. Although providing the

requested information is voluntary, a federal law

may require that you receive your federal payments

by electronic funds transfer. If so, failure to provide

any part of the requested information may delay or

prevent the federal government from making

payments to you.

SPECIAL NOTICE TO JOINT A

CCOUNT

HOLDERS

If y

our receiving bank and issuing agency allow a

joint account with a person who receives U

.S. gov-

ernment issued payment(s) and that person dies,

you must immediately contact your bank and

the

American Embassy/Consulate in your country

and/or the U.S. government agency that issued the

payment. Any U.S. government payment deposited

into a joint account after the death of a recipient

must be returned to the agency that issued the

payment.

IF YOUR ADDRESS CHANGES

If your address changes, you must inform the U.S.

ernment agency that issued the payment. If the

agency needs to contact you and cannot locate you,

your payment may be stopped.

CHANGING BANKS OR BANK ACCOUNTS

If you change your bank or your account number,

you m

ust notify the U.S. government agency that

issues your payments.

You may need to fill out a new sign-up form. Do not

close your old account until payments have started

coming to your new account.

BURDEN ESTIMATE STATEMENT

The estimated average burden associated with this

collection of inf

mation is 10 minutes per respon-

dent or record keeper, depending on the individual

circumstances. Comments concerning the accuracy

of this burden estimate and suggestions for

reducing this burden should be directed to the

Financial Management Services, Facilities

Management Division, Administrative Programs

Division, Records and Information Management

Program, 3700 East-West Highway, Hyattsville, MD

20782. This address should only be used for

comments and/or sug

estions concerning the

amount of time spent to collect the data. Do not

send the completed paperwork to the address

above for processing.

PLEASE READ THIS CAREFULLY