International Direct Deposit Enrollment 

Sign-Up Form
 

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. 

A. Person to Receive Payment 

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: 

B. Type of Payment (check only one) 

SOCIAL SECURITY CIVIL SERVICE RETIREMENT 

SUPPLEMENTAL SECURITY VA COMPENSATION 

INCOME OR PENSION 

RAILROAD RETIREMENT MILITARY ACTIVE 

MILITARY RETIRED MILITARY ANNUITANT 

OTHER (Specify) 

C. Bank Information 

NAME OF BANK: 

BANK PHONE NUMBER: 

ADDRESS: 

COUNTRY: 

BANK CODE: 

BRANCH CODE: (if necessary) 

ACCOUNT NUMBER OR IBAN 

THIS ACCOUNT IS: 

MY OWN ACCOUNT 

THIS ACCOUNT IS: 

CHECKING 

THIS ACCOUNT IS: 

US DOLLAR ACCOUNT 

PRINT NAME OF BANK OFFICIAL: 

SIGNATURE OF BANK OFFICIAL: 

DATE: 

A JOINT ACCOUNT 

SAVINGS 

LOCAL CURRENCY 

D. Certification 

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 

E. For Joint Account Holders 

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

HOLDERS on the back of this form. 

Name (print) 

Signature Date 

Optional Form 1199-I 

(June 2005) 
PLEASE READ THIS CAREFULLY 

PRIVACY ACT NOTICE 

Your social security number and the other information requested will allow the federal 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, authorizes 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 government 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 ACCOUNT 

HOLDERS 

If your receiving bank and issuing agency allow a 

joint account with a person who receives U.S. government 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. 

government 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 must 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 information is 10 minutes per respondent 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 suggestions concerning the 

amount of time spent to collect the data. Do not 

send the completed paperwork to the address 

above for processing.