You Can Make Your Payment by Credit Card--Electronic Application SSA-4589

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:

Privacy Act Statement
Collection and Use of Personal Information
Sections 204(a)(1) and 1631(b)(1)(A) of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of this information may prevent us from collecting your one-time or recurring credit card
payment(s) for your overpayment of Social Security benefits.
We will use the information you provide to process your one-time or recurring credit card
payment(s). We may also share the information for the following purposes, called routine uses:
1. To third party contacts such as private collection agencies and credit reporting agencies
under contract with the Social Security Administration (SSA) and other agencies,
including the Veterans Administration, the Armed Forces, the Department of the
Treasury, and State motor vehicle agencies, for the purpose of assisting SSA in
recovering program debt; and
2. To banks enrolled in the treasury credit card network to collect a payment or debt when
the individual has given his or her credit card number for this purpose.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt
Management System and 60-0231, entitled Financial Transactions of SSA Accounting and
Finance Offices. Additional information and a full listing of all our SORNs are available on our
website at https://www.ssa.gov/privacy/sorn.html.

1/23/2018 7:21 AM

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 (OMB) control number. We estimate that it will take about
5 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.