SSA-714: Social Security Administration Payment by Credit Card

Form SSA-714 PDF Details

Please fill in all the information below and return it with your request.

Card: CHECK ONE: Master Card, Visa, Discover, American Express, Diners Card.

Card holder: Credit Card Holder's Name (Print First, Middle Initial, Last Name) and Credit Card Holder's Address (Number & Street, City, State, ZIP Code).

Telephone: Daytime Telephone Number (Area Code Phone Number).

Card number: Amount Charged, Credit Card Number, Credit Card Expiration Date (XX-XXXX) and CVV (3 or 4 digits).

Signature: Credit Card Holder's Signature Authorization.

Credit card payment: Regular credit card rules will apply.