SSA-1712 Cover Letter - Statement of Reclamation Action

Form Approved
OMB No. 0960-0734

Social Security Administration
To: THE MANAGER
Institution #

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

Branch Transit #

Re:

BENEFICIARY INFORMATION
Beneficiary’s Name
U.S. Social Security Number & BIC

NOTICE OF RECLAMATION Canada Pmt Made in USD

PAYMENT INFORMATION
Trace Number,
Payment Date Amount (US$)
Original Payment

Depositor’s US$ Account Number With You
Company Entry Description SOC SEC
Date of Death – MM/DD/YY
Institution #

Branch Transit #

This is to notify you of the death of a United States Social Security beneficiary whose benefits were paid to your
institution via electronic funds transfer. Payments made after the month of death are not due to the deceased. Please
return the payment(s) described below as a return item, via remittance with the reference information to the address
listed below:
Payment must be payable to The Bank of Nova Scotia and must be in the form of bank draft drawn on the
remitting bank, money order, or certified cheque. Payment made through other instruments will be returned. In
order to ensure that funds are applied to the correct deceased beneficiary’s account, it is essential that you
quote the US Social Security Number (SSN) and send settlement to:
Bank:

The Bank of Nova Scotia, 95042
Shared Services, Non Branch Centralized Accounting Unit
888 Birchmount - 4th Floor
Scarborough, Ontario, M1K5L1

Bank Number: 0002
For Credit To:

Transit Number:

95042

BSN Cdn Gateway reclaims account - US$

Account #: 950420001112
If funds are no longer available in the depositor’s account, we would appreciate any attempt you can make to contact the
executor of the estate, or the next of kin, for a refund. For our records, please complete the attached information sheet
and return to the address above. Should you have any questions regarding the return of payment or if you are unable to
comply with this request, please call the undersigned. Thank you.
Regards,
Signature of SSA Official
Telephone Number

Form SSA-1712 (05-2014)

Print Name
Fax Number

Date

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 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 Systems of Records Notices
entitled, Recovery of Overpayments, Accounting and Reporting /Debt Management System,
60-0094; Master Files of Social Security Number (SSN) Holders and SSN Applications System,
60-0058; 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.

Form SSA-1712 (05-2014)