Form SSA-1414 Credit Card Payment Form

Form Approved
OMB No. 0960-0648

Social Security Administration

CREDIT CARD PAYMENT FORM
For your convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply.

We Accept All Major Credit Cards
Please fill in all the information below and return this form along with your bill to:
Social Security Administration
Office of Finance
P.O. Box 17042
Baltimore, MD 21235-7042
Note: Please read the Paperwork/Privacy Act Notice
Requestor's Name: (Please Print)

Credit Card Holder's Name:

This payment is for: (Please Print)

Credit Card Holder's Address: (Number, Street, City, State and Zip Code)

Daytime Telephone Number:

MasterCard

Visa

American Express

Discover

(Please Check One)
Area Code
Telephone Number
Social Security Number (SSN) or Employer Identification (EIN): Credit Card Number:

Amount Charged:
$
Credit Card Holder's Signature:

DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY

Form SSA-1414 (03-2014)

Credit Card Expiration Date:
Month

Card Verification Number:

Year

Authorization
Name

Date

Privacy Act Statement

Section 204 of the Social Security Act, as amended, authorizes the Social Security Administration
(SSA) to collect this information. The information you furnish on this form is voluntary. It is only
necessary to provide this information if you are making payment by credit card.
We rarely use the information you supply for any purpose other than obtaining payment that is due
to SSA. We will provide this information to the banks handling your credit card account and SSA's
account. Additionally, we may use the information for the administration and integrity of Social
Security programs.
We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following:
(1) To banks enrolled in the Department of Treasury credit card network to collect a payment
or debt when the credit card has been submitted for payment purposes;
(2) To enable a third party or an agency to assist Social Security to effect a salary or an
administrative offset or to an agent of SSA that is a consumer reporting agency for
preparation of a commercial credit report in accordance with 31 U.S.C. §§ 3711, 3717
and 3718;
(3) To a consumer reporting agency or debt collection agent to aid in the collection of
outstanding debts to the Federal Government;
(4) To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office or Department of Veteran Affairs);
(5) To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, state or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility for
Federally funded and administered benefit programs and for repayment of payments or delinquent
debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice 60-0231
(Financial Transactions of SSA Accounting and Finances Offices). The notice, additional
information regarding this form, and information regarding our programs and systems, are available
on-line at www.ssa.gov or at your local Social Security office.
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 it will take about 5 minutes to read the instructions, gather the facts, and
answer the questions. Please send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Form SSA-1414 (03-2014)