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Get SSA-714 2005

If you want more information about this you may call or write any Social Security Office. FORM SSA-714 07-2005. YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD 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 American Express Discover Diners Card Credit Card Holder s Name ---------------------------- Print First Middle Initial Last Name Number Street City State Zip Code Daytime Telephone Number --------------------------- Area Code Amount Charged Telephone Number - Credit Card Number Credit Card Expiration Date Month Year Authorization DO NOT WRITE IN THIS SPACE OFFICE USE ONLY --------------------------------------- Name Date PRIVACY ACT STATEMENT The Social Security Administration SSA has authority to collect the information requested on this form under 205 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose another means of payment for example by check or money order. If you choose the credit card payment option we will provide the information you give us to the banks handling your credit card account and SSA s account. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD 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. 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 American Express Discover Diners Card Credit Card Holder s Name ---------------------------- Print First Middle Initial Last Name Number Street City State Zip Code Daytime Telephone Number --------------------------- Area Code Amount Charged Telephone Number - Credit Card Number Credit Card Expiration Date Month Year Authorization DO NOT WRITE IN THIS SPACE OFFICE USE ONLY --------------------------------------- Name Date PRIVACY ACT STATEMENT The Social Security Administration SSA has authority to collect the information requested on this form under 205 of the Social Security Act. .

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