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SSA-714
You Can Make Your Payment By Credit Card
Download and Print
the SSA-714
Request may not be processed if the form is incomplete or illegible.
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
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