SSA-1712 Cover Letter - Statement of Reclamation Action

Form Approved
OMB No. 0960-0734
Social Security Administration________________________________________________________________________________________
To: THE MANAGER
Institution # __________

Branch Transit # __________

U.S. Social Security Administration
Office of International Operations
P.O. Box 1756
Baltimore, MD 21235-1756 U.S.A.

__________________________________________________
__________________________________________________
__________________________________________________

Re:

NOTICE OF RECLAMATION Canada Pmt Made in USD

__________________________________________________

BENEFICIARY INFORMATION
Beneficiary’s Name

Payment Date

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

U.S. Social Security Number & BIC
Depositor’s US$ Account Number With You
Company Entry Description
SOC SEC
Date of Death – MM/DD/YY:
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 to 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
remitting bank, money order, or certified cheque. Payment made through other instruments will be
returned. In order to ensure that funds are applied to the correct deceased beneficiary’s account, it is
essential that you quote the US Social Security Number (SSN) and send settlement to:
Bank:

The Bank of Nova Scotia, 95042
Shared Services, Non Branch Centralized Accounting Unit
888 Birchmount – 4th Floor
Scarborough, Ontario, M1K5L1

Bank Number: 0002

Transit Number: 95042

For Credit To: BSN Cdn Gateway reclaims account – US$
Account #:
950420001112
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 this request, please call the undersigned. Thank you.
Regards,
Signature of SSA Official

Print Name

Telephone Number

Fax Number

Form SSA-1712 (07-2009)

Date