Form SSA-1414 Credit Card Payment Form

Form SSA-1414 (12-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0648

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)

Daytime Telephone Number:
Area Code

MasterCard

Visa

American Express

Discover

Telephone Number

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

Amount Charged:

Credit Card Expiration Date:
Month

Card Verification Number

Year

Credit Card Holder's Signature:

Authorization
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY

Name

Date

Form SSA-1414 (12-2018)

Page 2 of 2

See Revised
Privacy Act Statement
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.

See Revised PRA
Statement
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.