Form SSA-1713 Statement of Reclamation Action

Form SSA-1713 (03-2017)
Discontinue Prior Editions
Social Security Administration

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0MB No. 0960-0734

STATEMENT OF RECLAMATION ACTION
TO: (SSA completes this section.)
Attn:
U.S. Social Security Administration
Office of Earnings and International Operations
P.O. Box 17769
Baltimore, MD 21235-7769

RE: (SSA completes this section.)
Beneficiary's Name
U.S. Social Security Claim Number
Country

(To be completed by 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:

D Requested amount is being/was returned by Direct Credit Transfer on
D Partial return is being/was returned by Direct Credit Transfer on

------

D Return declined or no action is being taken because: (please check all appropriate reasons)
D Account was closed by the estate.
D Permission was not granted by the estate.
D Permission was not granted by the joint account holder.
D Permission was not in accordance with our country's banking laws.
D 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
Address

Telephone Number

Form SSA-1713 (03-2017)

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See Revised Privacy Act
Privacy Act Statement
Collection and Use of Personal Information Statement Attached
Section 204 of the Social Security Act, as amended, and 31 CFR 210 of the Code of Federal Regulations authorize us to collect
this inf ormation. We will use the information to correct or adjust payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent us from
making an accurate decision on payments.
We rarely use the inf ormation 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).
A list of when we may share your information with others, called routine uses, is available in our System of R ecords Notices,
60-0058, entitled Master Files of Social Security Number (SSN) Holders and SSN Applications, 60-0090, entitled Master
Beneficiary Record, 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt Management System, and
60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits. Additional information about these 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 agencies through computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We can use the information from
these matching programs 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.

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, 6 401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our tim e estimate to this address, not the completed form.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information from Third Parties
Section 204 of the Social Security Act, as amended, and 31 C.F.R. 210 allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from making an accurate decision on benefit payments.
We will use the information to correct or amend benefit payment information. We may also
share this information for the following purposes, called routine uses:


To third party contacts such as private collection agencies and credit reporting agencies
under contract with Social Security Administration (SSA) and other agencies, including
the Veterans Administration, the Armed Forces, the Department of the Treasury, and
State motor vehicle agencies, for the purpose of their assisting SSA in recovering
program debt; and



To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for the SSA, as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned Agency
functions.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN), 60-0058, entitled Master Files of Social Security Number (SSN) Holders and SSN
Applications, as published in the Federal Register (FR) on December 29, 2010, at 75 FR 82121;
60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71
FR 1826; 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt
Management System, as published in the FR on August 23, 2005, at 70 FR 49354; and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the
FR on January 11, 2006, at 71 FR 1830. Additional information and a full listing of all our
SORNs are available on our website at https://www.ssa.gov/privacy.