Form SSA-1713 Statement of Reclamation Action

Form Approved
OMB NO: 0960-0734

Social Security Administration

STATEMENT OF RECLAMATION ACTION
TO: (SSA completes this section.)

RE: (SSA completes this section.)

Attn:

Beneficiary's Name

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

U.S. Social Security Claim Number
Country

(To be completed by the Financial Institution)
In response to your request for the return of United States Social Security entitlement(s) erroneously
issued to the beneficiary above, the action taken by this institution is as follows:
Requested amount is being/was returned by Direct Credit Transfer on
Partial return is being/was returned by Direct Credit Transfer on

(Date of Transfer)
(Date of Transfer)

Return declined or no action is being taken because: (please check all appropriate reasons)
Account was closed by the estate.
Permission was not granted by the estate.
Permission was not granted by the joint account holder.
Permission was not in accordance with our country's banking laws.
The Notice of Reclamation was forwarded to the estate and we have NOT received a reply.
Please contact them directly at the address below:
Executor of Estate/Joint Account Holder
Address
Telephone Number
Signature of Bank Official:___________________________________________________________
Printed Name of Bank Official/Title

Address
Telephone Number
Form SSA-1713 (04-2014)

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Paperwork Reduction Act Statement -This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

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 you provide 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
Seeor to another agency in accordance with approved
also disclose information to another person
Supplementary
routine uses, which include but are not limited to the following:
Documents for
revised Privacy Act
1. To enable a third party or an agency to
assist Social Security in establishing rights to
Statement.
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 System of Records Notices
entitled, Recovery of Overpayments, Accounting and Reporting /Debt Management System, 600094; Master Files of Social Security Number (SSN) Holders and SSN Applications System, 600058; 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.
Form SSA-1713 (04-2014)