Form SSA-1713 Statement of Reclamation Action

Approved OMB No._0960-XXXX

STATEMENT OF RECLAMATION ACTION

TO: (SSA completes this section.) RE: (SSA completes this section.)

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

(Date of Transfer)

[ ] Return declined or no action is being taken because: (please check all appropriate

reasons)

{ } 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 (04-2006)

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. 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.