Form Ssa 1199 Op16 – Fill Out and Use This PDF

Social Security Administration	Form Approved
	OMB No. 0960-0686

DIRECT DEPOSIT SIGN-UP FORM (Malta)

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

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

This account is:

My own account

A joint account

SECTION 2 (MAILING ADDRESS)

SECTION 3 (TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION)

THIS ACCOUNT MUST BE IN MALTESE LIRI

Name of Bank

Bank Phone Number

Address of Bank

Print Name of Bank Official

Signature of Bank Official

BANK CODE

BANK CODE

ACCOUNT NUMBER

Form SSA-1199-OP16 (08/2010)

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 the financial institution in your country.

WHEN YOU WILL RECEIVE YOUR DIRECT DEPOSIT PAYMENTS

Your benefit payment will be sent through the banking system in the country where your account is and will generally post to your account on the regular payment date.

However, delays in direct deposit can occur when a payment date fall on a holiday in the country of the receiving bank. With direct deposit, you will have immediate access to your money. This is the safest way of receiving your benefits.

INFORMATION ABOUT CURRENCY CONVERSION:

Your benefit payment will be sent through the banking system in the country where your account is and will generally post to your account on the regular payment date.

However, delays in direct deposit can occur when a payment date fall on a holiday in the country of the receiving bank. With direct deposit, you will have immediate access to your money. This is the safest way of receiving your benefits.

**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 American Embassy or Consulate in your area. Any Social Security payments deposited into a joint account after the death of a beneficiary must be returned to Social Security.

IF YOUR ADDRESS CHANGES:

If your address changes, you must inform the American Embassy or the Social Security Administration. If the Social Security Administration needs to contact you and cannot locate you, your payments may be stopped.

CHANGING BANKS OR BANK ACCOUNTS:

If you change your bank or your account, you must notify one of the following offices:

American Embassy	Social Security Administration
Office of American Services - FBU	Office of International Operations
Via Veneto 119/a	PO Box 17769
00187 Roma	Baltimore, MD 21235-7769
Italy	USA

You may needs 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.

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.

Form SSA-1199-OP16 (08/2010)