TN 28 (02-10)
GN 02210.154 Sample - Form SSA-4588, You Can Make Your Payment by Credit Card
The SSA-4588 form, (You Can Make Your Payment by Credit Card), provides debtors the option to pay their title II and title XVI debts by MasterCard,
VISA, Discover, American Express, or Diner’s Club credit cards. The form gives the
debtor the option to make a one-time payment or establish recurring monthly payments.
The Diners Club Card will only be accepted when it processes as a MasterCard or Discover
transaction. Acceptable Diners Club Cards should have the MasterCard or Discover Card
logo present on the card and meet the numerical requirements (See chart GN 02210.205B.1).
IMPORTANT: The SSA-4588 has been revised from a one-page form (front and back) to a two-page
form (front and back). There are six versions of the SSA-4588, one form for each PSC;
it contains the PSC-specific telephone number and hours of operation information.
To print a copy of this form go to Form SSA-4588 and choose the appropriate form for your PSC.