Statement of Reclamation Action

OMB 0960-0734

OMB 0960-0734

SSA uses Form SSA-1713 to collect information to determine if a Canadian bank is able to return erroneous payments, and to determine how and when it can return payments made after the death of a recipient who elects to have payments sent to Canada. Form SSA-1712 (or SSA-1712 CN) is the cover sheet SSA prepares to request return of a payment erroneously made after the death of the recipient. SSA sends Form SSA-1712 with Form SSA-1713. If the bank is the entity that reported the death via a returned payment, SSA does not request Forms SSA-1712 and SSA-1713. The respondents are Canadian financial institutions who received Social Security payments at recipients' request.

The latest form for Statement of Reclamation Action expires 2021-10-31 and can be found here.

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SSA-1712 - Notice of Reclamation

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-1712Cover Letter -Notice of Reclamation (Canada Payments Made in USD)Fillable PrintableForm and instruction
Form SSA-1712 CNCover Letter - Notice of Reclamation (Canada Payment Made in Canada)Fillable PrintableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.

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