Form Ssa-714 (07-2005)

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YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply. You may also pay by check or money order. We Honor Most Major Credit Cards Please fill in all the information below and return it with your request. Note: Please read Privacy Act Notice CHECK ONE ---------------------------------------------- > MasterCard Visa Discover American Express Diners Card Credit Card Holder’s Name ---------------------------- > Print First, Middle Initial, Last Name Credit Card Holder’s Address ------------------------- > Number & Street City, State, Zip Code Daytime Telephone Number --------------------------- > - - Area Code Telephone Number Amount Charged $ - - - Credit Card Number Credit Card Expiration Date Month Year Credit Card Holder’s Signature ----------------------- > Authorization DO NOT WRITE IN THIS SPACE OFFICE USE ONLY --------------------------------------- > Name Date PRIVACY ACT STATEMENT The Social Security Administration (SSA) has authority to collect the information requested on this form under § 205 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose another means of payment (for example, by check or money order). If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA’s account. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security Office. FORM SSA-714 (07-2005).

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