You Can Make Your Payment by Credit Card--Electronic Application

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 (OMB) control number. The OMB control number for this
information collection is 0960-0462. We estimate that it will take about 5 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.

Privacy Act Statement
Collection and Use of Personal Information

Sections 204(a)(1) and 1631(b)(1) of the Social Security Act, as amended, allow us to collect this
information. We will use the information you provide to process your payment(s) by credit card.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from processing your credit card payment.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us); and,
3. To banks enrolled in the treasury credit card network to collect a payment or debt
when the individual has given his/her credit card number for this purpose.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0231, entitled Financial Transactions
of SSA Accounting and Finance Offices. Additional information about this and other system of
records notices and our programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.