Form Ssa-1414 - Credit Card Payment Form printable pdf download

Form Ssa-1414 - Credit Card Payment Form

Form Approved

Social Security Administration

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 Code)

Daytime Telephone Number:

MasterCard

Visa

American Express

Discover

(Please Check One)

Area Code

Telephone Number

Credit Card Number:

Social Security Number

or Employer Identification

(SSN)

(EIN):

Amount Charged:

Credit Card Expiration Date:

Card Verification Number:

Month

Year

Credit Card Holder's Signature:

Authorization

DO NOT WRITE IN THIS SPACE

OFFICE USE ONLY

Name

Date

Form SSA-1414 (03-2014)

Form Ssa-1414 - Credit Card Payment Form