Form SSA-1414 Credit Card Payment Form

Form Approved
OMB No. 0960-0648

Social Security Administration

CREDIT CARD PAYMENT FORM
For your convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply.

We accept all major credit cards.

Please fill in all the information below and return this form along with your bill to:
Social Security Administration
Office of Finance
P.O. Box 17042
Baltimore, MD 21235-7042
Note: Please read the Paperwork/Privacy Act Notice
Requestor's Name: (Please Print)

Credit Card Holder's Name:

This payment is for: (Please Print)

Credit Card Holder's Address: (Number, Street, City, State and Zip Code)

Daytime Telephone Number:
Area Code

MasterCard

Visa

(Please Check One)

Telephone Number

Social Security Number (SSN) or Employer Identification (EIN):

Credit Card Number:

Amount Charged:

Credit Card Expiration Date:

$
Credit Card Holder's Signature:

DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY

Form SSA-1414 (01-2011)

American Express

Month

¨

Year

Authorization
Name

Date

Discover

Privacy Act Statement
See Revised Privacy Act Statement Attached
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;
(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 release of information from Social
Security records (e.g., to the Government Accountability Office or Department of
Veteran Affairs);
(5) 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 Finances 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.

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 it will take about 25 minutes to read the instructions,
gather the facts, and answer the questions. Please send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Form SSA-1414 (01-2011)

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Notice

Section 204 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to process payments.
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. However, failure to provide all or
part of the information could prevent us from processing your payment correctly.
We rarely use the information you supply for any purpose other than to process
payment(s) due to Social Security Administration. However, we may use it 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 enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs (e.g., to the
Bureau of the Census and private concerns under contract to Social Security).
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 or 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 entitled, Transactions of SSA Accounting and Finance Offices, 60-0231. This
notice, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local
Social Security office.