FORM SSA-714 (07-2005)
YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD
As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply.
You may also pay by check or money order.
We Honor Most Major Credit Cards
Please fill in all the information below and return it with your request.
Note: Please read Privacy Act Notice
CHECK ONE ---------------------------------------------- >
MasterCard Visa Discover
American Express Diners Card
Credit Card Holder’s Name ---------------------------- >
Print First, Middle Initial, Last Name
Credit Card Holder’s Address ------------------------- >
Number & Street
City, State, Zip Code
Daytime Telephone Number --------------------------- >
Area Code Telephone Number
Amount Charged $
Credit Card Number
Credit Card Expiration Date
Month
Year
Credit Card Holder’s Signature ----------------------- >
Authorization
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY --------------------------------------- >
Name Date
PRIVACY ACT STATEMENT
The Social Security Administration (SSA) has authority to collect the information requested on this form under § 205 of the Social Security Act. Giving us this information is
voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose
another means of payment (for example, by check or money order).
If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA’s account. We may also
provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and
other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security Office.
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