Form SSA-4588 You Can Make Your Payment By Credit Card

Form Approved
OMB No. 0960-0462

YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD
USTED PUEDE PAGAR CON TARJETA CRÉDITO
For your convenience, we offer you the option to make your payment by credit card. If you wish to make recurring credit card
payments, please read the terms of authorization on page 3 before signing. The letter we sent you with this form explains
other ways you can pay back the overpayment and/or gives a telephone number you can call if you have any questions.
Para su conveniencia, le ofrececemos la opción de pagar con tarjeta de crédito. [Insert added sentence.] La carta que le
enviamos con este formulario le indica otras alternativas para pagar el sobrepago y le da un número de teléfono al que
puede llamar si tiene preguntas.

We accept Visa, MasterCard, American Express, Discover and Diners Club.
Nosotros aceptamos Visa, MasterCard, American Express, Discover, y Diners Club
Then Do This...
If You Want To...
[Insert translation]
[Insert translation]
1. Make a one-time payment by
phone
[Insert translation.]

Before you phone us, please complete the information on pages 1 and 2. Then, call
toll-free 1-800-XXX-XXXX between the hours of X:XXAM - X:XXPM (Monday Friday). We will process your transaction over the phone.
Antes de llamarnos, complete la información solicitada abajo y llámenos
1-800-XXX-XXXX al número gratis de X:XXAM a X:XXPM (de lunes a viernes).
[Insert translation]

2. Make a one-time payment by mail. Please complete the information on pages 1 and 2 and sign and date this form.
Return pages 1 and 2 to the Social Security Administration in the enclosed
envelope to make a one-time payment. This form will be used as an Authorization
[Insert translation].
Agreement and cannot be processed without your signature.
[Insert translation]
3. Make a recurring monthly payment Please complete pages 1-3 and sign and date this form. Return pages 1 and 2 to
by mail.
the Social Security Administration in the enclosed envelope. Keep page 3 for your
[Insert translation.]
records. This form will be used as an Authorization Agreement for recurring
payments and cannot be processed without your signature.
Favor de completar toda la información solicitada abajo. Devuelva este formulario a
la Administración del Seguro Social en el sobre adjunto. [Insert translation]
Beneficiary Information
First Name (Nombre)

[Insert Translation]
Middle Initial (Inicial)

Last Name (Apellido)

Print Account Number Shown on the Notice (Escriba el numero de cuenta que aparece en al aviso)

Credit Card Holder Information [Insert Translation]
First Name (Nombre)

Middle Initial (Inicial)

Address
Número y calle
State
Estado

Last Name (Apellido)

Apt. Number
City
Número de apartamento Ciudad
ZIP Code
Zona postal

Form SSA-4588-OPX (xx-xxxx) Destroy Prior Editions

Daytime Telephone Number (including area code)
Número de teléfono diurno (incluye código de area)
1

Credit Card Information [Insert translation]
CHECK ONLY ONE (MARQUE UNO)

Visa

MasterCard

Credit Card Number
Número de tarjeta de crédito
-

-

-

Discover

American Express

Diners Club

Expiration Date
Amount to be Charged Each Month
Fecha de expiración de la tarjeta de Cantidad cobrada
crédito

$

Frequency of Payments [Insert translation]
Please indicate if you would like to make a one-time payment or a recurring payment. CHECK ONLY ONE.
[Insert translation.]
One-time Payment--Go to the Authorization Section below and sign under Credit Card Holder's Signature and
date the form. Mail pages 1 and 2 to the Social Security Administration in the enclosed envelope.
[Insert translation]
OR
Recurring Payment--Complete the next section, then sign below under Credit Card Holder's Signature and date
the form. Mail pages 1 and 2 to the Social Security Administration in the enclosed envelope.
[Insert translation]

Date of First Payment/Date of Last Payment [Insert translation]
Please indicate below when you want your first payment and last payment to be. Also, enter this first and last payment date
information on page 3 for your records. Your credit card will be charged the amount you indicate above.
[Insert translation]
First Payment (month, year)
Comenzar (mes, año)

Last Payment (month, year) *This will be the last month your
card will be charged.
Terminar (mes, año) [Insert translation].

Authorization [Insert translation]
Regular credit card rules apply.
Las reglas normales de la tarjeta de credito aplican.
Credit Card Holder's Signature (Firma del Poseedor de la Tarjeta de Credito)

Date (Fecha)

DO NOT WRITE IN THE SPACE BELOW--FOR OFFICE USE ONLY
NO ESCRIBA EN ESTE ESPACIO--USO OFICIAL SOLAMENTE

Received at SSA: Date/Sign

Form SSA-4588-OP1 (xx-xxxx)

Sent to RAU: Date/Sign

Destroy Prior Editions

2

Received at MATPSC RAU: Date/Sign

Retain this Page for Your Records [Insert translation]
Terms and Conditions of Authorization
This form will be used by SSA to charge your credit card for the amount and time period you
specified on pages 1 and 2.

Authorization: Review and complete the Authorization Agreement on pages 1 and 2 of this form. If you are authorizing
recurring payments, each payment shall be the same as if it were an instrument personally signed by you. NOTE: You
must provide your credit card information with the Authorization Agreement.
[Insert Translation]
Cancellation: This authorization will remain in effect until cancelled by either you, the Social Security Administration, or
the financial institution. You must notify the Social Security Administration to discontinue automatic payments by calling
1-800-XXX-XXXX between X:XXAM--X:XXPM.
[Insert Translation]
Stop Payment: You have the right to stop payment of a charge by timely notification to the Social Security
Administration 15 days prior to your credit card being charged.
[Insert Translation]
Payment Amount: The amount charged to your credit card will be the amount you enter on page 2 of this form.
[Insert Translation]
Please record below the date you want your first payment and last payment to be. This should be the same date you
entered on page 2. Keep this page for your records.
[Insert translation]

First Payment (month, year)
Comenzar (mes, año)

Last Payment (month, year)
Terminar (mes, año)
Paperwork Reduction Act Notice
Aviso de la ley de Reduccion de documentos de trabajo

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read
the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.
Ley para la Reducción de Documentos de Trabajo- Esta recopilación de información cumple con los requisitos de 44
U.S.C. § 3507, según enmendada por la sección 2 de la Ley de Reducción de Documentos de Trabajo de 1995. No es
requisito que usted conteste estas preguntas a menos que mostremos un número de control válido de la oficina de
Administración y Presupuesto. Estimamos que le tomará 10 minutos leer las instrucciones, reunir los datos y llenar el
formulario. Puede enviar comentarios sobre nuestro estimado del tiempo para completar el formulario a: SSA, 6401
Security Blvd., Baltimore, MD. 21235-6401. Por favor sólo envíe comentarios sobre nuestro estimado, no sobre el
formulario, a la dirección mencionada arriba.
Form SSA-4588-OP1 (xx-xxxx) Destroy Prior Editions

3

Privacy Act Notice
Aviso de la Confidencialidad

See Revised Privacy Act Statement Attached
The Social Security Administration (SSA) has authority to collect the information requested on pages 1 and 2 under
section 204 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need
this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose
another means of payment (for example, by check or money order).
If you choose the credit card payment option, we will provide the information you give us to the financial institutions
handling your credit card account and SSA's account. We may also provide this information to another person or
government agency to comply with federal laws requiring the release of information from our records. You can find
these and other routine uses of information provided to SSA listed in the Federal Register. If you want more
information about this, you may call or write any Social Security Office.
We may also use the information you give us when we match records by computer. Matching programs compare our
records with those of other Federal, State, or local government agencies. Many agencies may use matching programs
to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this, even
if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in
Social Security offices. If you want to learn more about this, contact any Social Security office.

La Administración del Seguro Social tiene la autoridad para solicitar la información al dorso de este formulario bajo la
Sección 204 de la ley del Seguro Social. Darnos la información es voluntaria. Usted no está obligado a darnos la
información. Esta información es necesaria solamente si decide hacer su pago por tarjeta de crédito. Si escoge otro
método de pago no es necesario completar este formulario (por ejemplo, por cheque o giro postal).
De usted escoger la opción de pagar por tarjeta de crédito, le proveeremos la información que usted nos dé a los
bancos que manejan su cuenta y la cuenta del Seguro Social. También podemos proveer la información que nos dé a
otras personas o agencias del gobierno de acuerdo con la ley federal que requiere que revelemos información de
nuestros registros. En el Registro Federal (Federal Register), usted encontrará estos y otros usos rutinarios de
información provista al Seguro Soical. Si usted desea más información, puede llamar o escribir a cualquier oficina de
Seguro Social.
También podemos usar la información que usted nos dá cuando comparamos registros de computadoras. Los
programas de comparación cotejan nuestros registros con los de otras agencias del gobierno federal, estatal, o local.
Muchas agencias pueden usar estos programas de comparación para establecer o verificar si una persona tiene
derecho a programas de beneficios pagados o administrados por el gobierno federal. La Ley nos permite hacer esto
aunque usted no esté de acuerdo.
Explicaciones sobre estas y otras razones por las cuales la información de usted se puede usar o revelar, están
disponibles en las oficinas de Seguro Social. Si desea más información, comuníquese con cualquier oficina de Seguro
Social.

Form SSA-4588-OP1 (xx-xxxx) Destroy Prior Editions

4

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 204 of the Social Security Act, as amended, authorizes us to collect the information requested on this
form. The information you provide will be used only if you choose to make a payment by credit card. Your
response is voluntary. However, failure to provide the requested information will prevent us from processing
your credit card payment. You do not have to complete this form if you choose to make payment by check
or money order.
We rarely use the information provided on this form for any purpose other than to process credit card
payments. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the
information provided on this form in accordance with approved routine uses, which include but are not
limited to the following:
1. To banks enrolled in the Department of Treasury credit card network to collect a payment or debt
when the credit card has been submitted for payment purposes;
2. To enable a third party or an agency to assist SSA to effect a salary or an administrative offset or to
an agent of SSA that is a consumer reporting agency for preparation of a commercial credit report in
accordance with 31 U.S.C. §§ 3711, 3717 and 3718;
3. To a consumer reporting agency or debt collection agent to aid in the collection of outstanding debts
to the Federal Government.
4. To comply with Federal laws requiring the disclosure of the information from our records; and
5. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of
SSA programs.
We may also use the information you provide when we match records by computer. Computer matching
programs compare our records with those of other Federal, state or local government agencies. Information
from these matching programs can be used to establish or verify a person’s eligibility for federally funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
The law allows us to do this even if you do not agree to it.
A complete list of routine uses for this information is contained in our System of Records Notice 60-0231
(Financial Transactions of SSA Accounting and Finance Offices). Additional information regarding this
form and our other systems of records notices and Social Security programs are available from our Internet
website at www.socialsecurity.gov or at your local Social Security office.
SSA Will Attach A Revised Spanish PA Statement As Well