SSA-1712 CN Cover Letter - Notice of Reclamation (Canada Payment Mad

Form Approved
OMB No. 0960-0734
Social Security Administration________________________________________________________________________________________
To: THE MANAGER
Institution # __________

Branch Transit # __________

U.S. Social Security Administration
Office of International Operations
P.O. Box 1756
Baltimore, MD 21235-1756 U.S.A.

__________________________________________________
__________________________________________________
__________________________________________________

Re:

NOTICE OF RECLAMATION Canada Pmt Made in CAD

__________________________________________________

BENEFICIARY INFORMATION
Beneficiary’s Name

Payment Date

Amount
Original
(US$)

PAYMENT INFORMATION
Amount
Trace Number,
paid in CA$ Original Payment

U.S. Social Security Number & BIC
Depositor’s Account Number With You
Company Entry Description
SOC SEC
Date of Death – MM/DD/YY:
Institution #
Branch Transit #
This is to notify you of the death of a United States Social Security beneficiary whose benefits were paid to your
institution via electronic funds transfer. Payments made after the month of death are not due the deceased.
Please return the payment(s) described below as a return item, via remittance with the reference information
to the address listed below:
Payment must be payable to The Bank of Nova Scotia and must be in the form of bank draft drawn on the
remitting bank, money order, or certified cheque. Payment made through other instruments will be
returned. In order to ensure that funds are applied to the correct deceased beneficiary’s account, it is
essential that you quote the US Social Security Number (SSN) and send settlement to:
Bank:

The Bank of Nova Scotia, 95042
Shared Services, Non Branch Centralized Accounting Unit
888 Birchmount – 4th Floor
Scarborough, Ontario, M1K5L1

Bank Number: 0002

Transit Number: 95042

For Credit To: BNS Cdn Gateway reclaims account – CA$
Account #:
950420001112
If funds are no longer available in the depositor’s account, we would appreciate any attempt you can make to
contact the executor of the estate, or the next of kin, for a refund. For our records, please complete the attached
information sheet and return to the address above. Should you have any questions regarding the return of
payment or if you are unable to comply with this request, please call the undersigned. Thank you.
Regards,
Signature of SSA Official

Print Name

Telephone Number

Fax Number

Date

__________________________________________________________________________________________
Form SSA-1712-CN (07-2009)

Privacy Act Statement
Collection and Use of Personal Information

Section 204 of the Social Security Act (42 U.S.C. § 404), as amended, authorizes us to collect
this information. We will use the information to assist us in correcting or adjusting payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate decision on payments.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use it 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 enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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 or 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 our Systems of Records
Notices entitled, Recovery of Overpayments, Accounting and Reporting /Debt Management
System, 60-0094; Master Files of Social Security Number (SSN) Holders and SSN Applications
System, 60-0058; and, Master Beneficiary Record, 60-0090. These notices, additional
information regarding this form, and information regarding our systems and programs, are
available on-line at www.socialsecurity.gov or at any local Social Security office.