Payment Option – Fill Online Please enable JavaScript in your browser to complete this form.PAYMENT OPTIONSSocial Security NumberName of BeneficiaryPlease select one (1) payment option and provide all of the relevant information:1.WIRE TRANSFER PAYMENT1.WIRE TRANSFER PAYMENT1. WIRE TRANSFER PAYMENT (copy)1. WIRE TRANSFER PAYMENT (copy) (copy)1. WIRE TRANSFER PAYMENT (copy) (copy) (copy)NumbersNumbers (copy)Numbers (copy) (copy)Single Line TextSingle Line Text (copy)PhoneEmail *2.DIRECT DEPOSIT TO A LOCAL ACCOUNT IN ANTIGUA & BARBUDA2.DIRECT DEPOSIT TO A LOCAL ACCOUNT IN ANTIGUA & BARBUDA (copy)NumbersSingle Line TextSingle Line Text (copy)Single Line Text (copy) (copy)PhoneEmail *Date / TimeSignatureClear SignatureTO BE CERTIFIED BY ANY OF THE FOLLOWING PERSONS BY TICKING THE SPECIFIED PROFESSION:Notary Public ( ) Justice of the Peace ( ) Caricom Social Security Sys. ( ) Anu & Bar High Comm ( )Print NameDate SignatureClear SignatureOFFICIAL STAMP/SEALClear SignaturePhoneSubmit
