Form SSA-1713 Statement of Reclamation Action

Form Approved
OMB No. 0960-0734

STATEMENT OF RECLAMATION ACTION
TO: (SSA completes this section.)

RE: (SSA completes this section.)
Beneficiary’s Name

Attn. _____________________________
U.S. Social Security Administration
Office of International Operations
P.O. Box 1756
Baltimore, MD 21235-1756, USA

U.S. Social Security Claim Number

Country

(To be completed by the Financial Institution)
In response to your request for the return of United States Social Security entitlement(s)
erroneously issued to the beneficiary above, the action taken by this institution is as follows:
[

]

Requested amount is being/was returned by Direct Credit Transfer on ______________.
(Date of Transfer)

[

]

Partial return is being/was returned by Direct Credit Transfer on ___________________.

[

]

Return declined or no action is being taken because: (please check all appropriate
reasons)

(Date of Transfer)

{

}

Account was closed by the estate.

{

}

Permission was not granted by the estate.

{

}

Permission was not granted by the joint account holder.

{

}

Permission is not in accordance with our country’s banking laws.

{

}

The Notice of Reclamation was forwarded to the estate and we have NOT
received a reply. Please contact them directly at the address below:

Executor of Estate/Joint Account Holder
Address

Telephone Number

Signature of Bank Official: ________________________________________________________
_________________________________________________________________
Printed Name of Bank Official/Title
_________________________________________________________________
Address
_________________________________________________________________
_________________________________________________________________
Telephone Number
_____________________________________________________________________________________________
Form SSA-1713 (07-2009)

PAPERWORK REDUCTION ACT STATEMENT
This information 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. You may send
comments on our time estimate above to: SSA, 1338 Annex building, Baltimore, MD 21235-0001.
Only comments relating to our time estimate should be provided, not the completed form.

See Revised Paperwork Reduction Act Statement

PRIVACY ACT STATEMENT
Section 204 of the Social Security Act, as amended, authorizes us to collect the requested
information on this form. The information you provide will be used to assist Social Security
Administration (SSA) in reclaiming erroneously issued payments. Your response is voluntary.
However, failure to provide the requested information will prevent SSA from collecting payments
due to our Agency.

See revised
We rarely use the information provided
on this
Privacy
Actform for any purpose other than for the reasons
stated above. However, we may use
it
for
the
administration and integrity of Social Security
Statement below.
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 a congressional office in response to an inquiry made to that office at the request of
the subject of a record;

2)

To third party contacts such as private collection agencies and credit reporting agencies
under contract with SSA and other agencies, including the Veteran’s Administration, the
Armed Forces, the Department of the Treasury, and State motor vehicle agencies, for the
purpose of their assisting SSA in recovering program debt;

3)

To contractors and other Federal agencies as necessary, to assist SSA in the efficient
administration of its programs; and,

4)

To facilitate statistical research, audit or investigate activities necessary to assure that
integrity of Social Security programs.

A complete list of routine uses for this information is available in the System of Records Notice 600094. The 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.

Form SSA-1713 (07-2009)

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. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
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.

Privacy Act Statement
Collection and Use of Personal Information

Section 204 of the Social Security Act (42 U.S.C. § 404), as amended, authorizes us to collect
this information. We will use the information you provide to assist us in correcting or adjusting
payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate decision on payments.
We rarely use the information you supply for any purpose other than the reason stated above.
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 our System of Records Notices
entitled, Recovery of Overpayments, Accounting and Reporting /Debt Management System, 600094; Master Files of Social Security Number (SSN) Holders and SSN Applications System, 600058; and Master Beneficiary Record, 60-0090. These notices, additional information regarding
this form, and information regarding our systems and programs, are available on-line at
www.socialsecurity.gov or at any local Social Security office.