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Antigua & Barbuda Social Security Board ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION FORM Please complete and email this form to: remittance@socialsecurity.gov.ag after your EFT transaction. EFT transaction information Company Name: Antigua Barbuda Social Security Board BANKING DETAILS Payee Name on Account: Antigua Barbuda Social Security Board Account Number: Name of Bank: Branch Location: Branch Code: Swift Code: Account Type: 100-000-67 Caribbean Union Bank Friar’s Hill Road (070-28201) CUNBAGAG Cheque Please complete the below form in details after your EFT payment. Employer Name: _______________________________________________________________ Registration No.

: __________________________________ (six (6) digit only) Remittance Month: ________________________________ (mm/yyyy) EFT Transaction/Receipt No: ________________________ EFT Transaction Amount: __________________________ Remember to sign and date all R5As then email to remittance@socialsecurity.gov.ag Having trouble? Please contact us at 1 (268) 736-3000/1/2/3 or email us at customerserv@socialsecurity.gov.ag