Form SSA-1712 Cover Letter -Notice of Reclamation (Canada Payments Mad

Form SSA-1712 (04-2017)

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Form Approved
OMB No. 0960-0734

Social Security Administration
To: THE MANAGER
Institution #

U.S. Social Security Administration
Office of Earnings and International Operations
P.O. Box 17769
Baltimore, MD 21235-7769

Branch Transit #

Re:

BENEFICIARY INFORMATION
Beneficiary’s Name

NOTICE OF RECLAMATION Canada Pmt Made in USD

PAYMENT INFORMATION
Trace Number,
Payment Date 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 – 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
For Credit To:

Transit Number:

95042

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
Telephone Number

Print Name
Fax Number

Date

Form SSA-1712 (04-2017)

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PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 204 of the Social Security Act, as amended, and 31 CFR 210 of the Code of Federal
Regulations authorize us to collect this information. We will use the information to correct or adjust
payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate decision on payments.
We rarely use the information you supply for any purpose other than what we state above, however,
we may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our
System of Records Notices, 60-0058, entitled Master Files of Social Security Number (SSN) Holders
and SSN Applications, 60-0090, entitled Master Beneficiary Record, 60-0094, entitled Recovery of
Overpayments, Accounting and Reporting/Debt Management System, and 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits. Additional information about
these and other system of records notices and our programs are available from our Internet website
at www.socialsecurity.govor
www.socialsecurity.gov at your local Social Security office.
We may share the information you provide to other agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or local
government agencies. We can use the information from these matching programs to establish or
verify a person's eligibility for federally funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
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. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may
send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.