Form SSA-1414 Credit Card Payment Acknowledgement Form

See Revised Privacy Act Statement Attached

See Revised PRA Statement Attached

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Section 204 of the Social Security Act, as amended, authorizes the Social Security
Administration (SSA) to collect this information. The information you furnish on this
form is voluntary. It is only necessary to provide this information if you are making
payment by credit card.
We rarely use the information you supply for any purpose other than obtaining payment
that is due to SSA. We will provide this information to the banks handling your credit
card account and SSA’s account. Additionally, we may use the information for the
administration and integrity of Social Security programs.
We may also disclose information to another person or to another agency 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 Social Security 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;
(4) To a consumer reporting agency or debt collection agent to aid in the
collection of outstanding debts to the Federal Government;
(5) To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office or Department of
Veteran Affairs)
(6) To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by 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 and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records
Notice 60-0231 (Financial Transactions of SSA Accounting and Finance Offices). The
notice, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 5
minutes to read the instructions, gather the facts, and answer the questions. Please send
only comments relating to our time estimate to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.