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Ssa 1199 Op112
Ssa 1199 Op112
Ssa 1199 Op112
Telephone Number: THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
Type Amount
PAYEE CERTIFICATION JOINT ACCOUNT HOLDER'S CERTIFICATION (optional)
I (beneficiary or representative payee) certify that I have read I certify that I have read and understand the back of this form,
and understand the back of this form. In signing this form, I including the SPECIAL NOTICE TO JOINT ACCOUNT
authorize the Social Security Administration to send this HOLDERS.
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.
ADDRESS OF BANK
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.