Form SSA-714 at a glance
What it is: Form SSA-714 of the Social Security Administration: you can make your payment by credit card.
Who signs: Under Authorization, the credit card holder signs on the Credit Card Holder's Signature line.
A filled-in Form SSA-714 example: a Visa payment
How to fill out Form SSA-714, box by box
Check one
Under CHECK ONE, mark Master Card, Visa, Discover or American Express Diners Card.
Credit Card Holder's name, address and telephone
Under Credit Card Holder's Name, print First, Middle Initial, Last Name.
Under Credit Card Holder's Address, enter the Number & Street and the City, State, ZIP Code.
Under Daytime Telephone Number, enter the Area Code and the Phone Number.
Amount, card number, expiration date and CVV
Enter the Amount Charged $ and the Credit Card Number.
Enter the Credit Card Expiration Date (XX-XXXX) as Month and Year, and the CVV (3 or 4 digits).
Authorization
Under Authorization, the credit card holder signs on the Credit Card Holder's Signature line.
More rules for Form SSA-714
Regular credit card rules apply. You may also pay by check or money order. Fill in all the information on the form and return it with your request.
You do not need to complete the payment stub if you submit another form of payment (e.g., check or money order).
Providing the information is voluntary, but not providing all or part of the information on the payment stub may prevent processing your payment.
Sources
[1] Form SSA-714 (03-2026), Social Security Administration (the Official source link on this page).