Credit Card Payment Form

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 204 and 702 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may impact our processing of your credit card payment.
We will use the information you provide to process your credit card payment. We may also
share the information for the following purposes, called routine uses:


To banks enrolled in the treasury credit card network to collect a payment or debt when the
individual has given his/her credit card number for this purpose; and



To another Federal agency that has requested the Social Security Administration (SSA) to
effect an administrative offset under common law or under 31 U.S.C. 3716 to help collect a
debt owed to the United States.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0231, entitled Financial Transactions of SSA Accounting and Finance Offices, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1847. Additional
information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy/.

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
(OMB) control number. We estimate that it will take about 2 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.