Direct-Deposit Data Requirements 



FROM BENEFICIAII(S) 



Name of Beneficiary (s) 



Social Security Account Number (s) 



Financial Organization Name and Address 



Name and Number of Account to which Deposits Are to be Made 



Mailing Address (for notices) 



Statement Advising of Requirement to Report a Change of Mailing 

 Address 



Signature of Beneficiary(s) or Authorized Representative 



Date Submitted to SSA 



FROM FINANCIAL ORGANIZATION 



Statement Certifying the Accuracy of Financial Organization 

 Information Reported by the Beneficiary 



Single Point of Deposit Address 



Employer Identification Number (EIN) 



2 

 Transit and Routing Number 



Signature of Authorizing Officer 



1 



In some cases, branch banking is state wide and a bank might need several 



regional points of deposit. To accommodate these types of systems a 



single digit might be added to the EIN to designate specified regions . 



2 

 Required for EFT only. At present neither credit unions nor savings and 



loans are assigned Transit and Routing Numbers. 



Figure 3.1 



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