Form SSA-1414 "Credit Card Payment Form"

What Is Form SSA-1414?

This is a legal form that was released by the U.S. Social Security Administration on December 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest available edition released by the U.S. Social Security Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SSA-1414 by clicking the link below or browse more documents and templates provided by the U.S. Social Security Administration.

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Form SSA-1414 (12-2018)
Discontinue Prior Editions
Page 1 of 2
Social Security Administration
OMB No. 0960-0648
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)
Daytime Telephone Number:
MasterCard
Visa
American Express
Discover
Area Code
Telephone Number
(Please Check One)
Social Security Number (SSN) or Employer Identification (EIN): Credit Card Number:
Credit Card Expiration Date:
Amount Charged:
Card Verification Number
Month
Year
Credit Card Holder's Signature:
Authorization
Name
Date
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
Form SSA-1414 (12-2018)
Discontinue Prior Editions
Page 1 of 2
Social Security Administration
OMB No. 0960-0648
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)
Daytime Telephone Number:
MasterCard
Visa
American Express
Discover
Area Code
Telephone Number
(Please Check One)
Social Security Number (SSN) or Employer Identification (EIN): Credit Card Number:
Credit Card Expiration Date:
Amount Charged:
Card Verification Number
Month
Year
Credit Card Holder's Signature:
Authorization
Name
Date
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
Form SSA-1414 (12-2018)
Page 2 of 2
Privacy Act Statement
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 5 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.
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