Form SSA-1712 Cover Letter - Statement of Reclamation Action

Social Security Administration

THE MANAGER
Institution #
Branch Transit #

To:

U.S. Social Security Administration
Office of International Operations
P.O. Box 1756
Baltimore, MD 212351756 U.S.A.

Re:

BENEFICIARY INFORMATION
Beneficiary's Name

NOTICE OF RECLAMATION
Canada Pmt. Made in US0

Payment Date

-

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

U.S. Social Security Number & BIC
Depositor's US$ Account Number With You
Company Entry Description
SOC SEC

Date of Death-MMIDDIYY:
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 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 remittinn bank, money order, or certified cheque. Payment made through other
instruments will be returned. In order to ensure that funds are asdied to the correct deceased
beneficiarv's account, it is essential that YOU auote the US Social Securitv Number (SSN) and
send settlement to:
Bank:

The Bank of Nova Scotia, 95042
Shared Services, Non Branch Centralized Accounting Unit
888 Birchmount - 4" Floor
Scarborough, Ontario, M I K 5L1

Bank Number:

Transit Number:

For Credit To:

BNS Cdn Gateway reclaims account - US$

95042

Account #: 950420001 1 12
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 thls request. please call the undersigned. Thank you.
Regards,

rn Nme

re of SSA Offlclel

1

-one

Number

Form SSA-1712 (4-2006)

I

EwmmE

I&
1