Social Security Administration
Billing Statement
Important Information
Susan A Patrick
1234 5th Avenue
Huntington NY 10101
(Bar Code goes here)
STATEMENT DATE: 11/05/02
ACCOUNT NUMBER: 12345678901
AMOUNT DUE: $110.00
BALANCE FROM PREVIOUS STATEMENT $310.00
PAYMENT RECEIVED - 10/12/02 - THANK YOU $5.00
NEW BALANCE $305.00
PAYMENT OF NEW BALANCE OR AMOUNT DUE
MUST REACH US BY: 11/23/02
PAST DUE PAYMENT
This statement concerns an overpayment of Social Security benefits paid in error to
SUSAN PATRICK, C1; JOE A PATRICK, C2; JOHN A PATRICK, C3; and FRED PATRICK, C4.
We did not receive the full payment of $85.00 which was due by 10/23/02. Please send
us the amount shown below, which reflects this month's payment plus the remainder
from last month's amount due.
Enclosure(s):
Refund Env.
See Next Page
12345678901 Page
2 of 4
If we don't receive the amount due, we can collect the money owed us:
-
•
from Federal income tax refunds or other Federal payments you may be due, or
-
•
from future Social Security benefits, or
-
•
through a Federal court lawsuit.
We can also report your overdue debt to credit bureaus.
To request to repay a smaller amount monthly over a longer period of time, please
call us at the telephone number below.
If you have mailed the past due amount of $80.00 within the past week, you should
only make this month's payment of $30.00.
If you have any questions, you may call us at 718-557-6600 (LOCAL CALL). The office
hours are Monday through Friday, 8:00 AM TO 5:45 PM ET. Please have this statement
available when you call.
If you call us using a TDD machine, please pause after you type a few words. This
will give us time to transfer your call to the TDD line.
12345678901 Page
3 of 4
OMB
No 0960-0462
PAYMENT STUB
-
•
Return the bottom portion of the stub with your payment.
-
•
Use the enclosed envelope to mail your payment to us; make sure our address shows
through the window of the envelope.
-
-
•
Do not enclose any correspondence with your remittance. Send any correspondence to:
Social Security Administration, Northeastern Program Service Center, PO Box 314400,
Jamaica, NY 11431-9887
-
•
If you have changed your address or telephone number, be sure to check the box below
and write your new address or telephone number in the space provided.
-
•
If you pay by check or money order, include the Social Security Account Number as
shown below and make the check or money order payable to "Social Security Administration."
-
•
If paying by credit card, complete the appropriate information below and return it
in the enclosed envelope
OR
to pay by phone, call 718-557-6600 (LOCAL CALL), during the hours 8:00 AM TO 5:45
PM ET. Please have this notice and your credit card available when you call.
SSA-53-EP DETACH
HERE. DO NOT STAPLE.
ACCOUNT NUMBER: 123-45-6789-01 []MASTERCARD []VISA []DISCOVER
SUSAN PATRICK
|
|
|
Credit Card Number
|
Exp Date
|
|
AMOUNT DUE:
|
$110.00
|
|
|
|
DATE DUE:
|
November 23, 2002
|
________________
|
_________
|
|
|
|
|
|
|
PAYMENT AMOUNT
|
$_____________
|
Cardholder's Signature
|
Date
|
|
|
|
___________________
|
_________
|
Check box if your address or
[] telephone number has changed.
Make changes below.
|
_________________________________
_________________________________
|
SOCIAL SECURITY ADMINISTRATION
PO BOX 3430
PHILADELPHIA PA 19122-9985
| | | | | | | | | | | | | | | | | | | | | | | | | |
|
31234567890100000100000001000034500000034500000034500OR0000000006
12345678901 Page
4 of 4
Privacy Act and Paperwork
Reduction Act Statements
The Social Security Administration (SSA) has authority to collect the information
requested on the PAYMENT STUB under section 204 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 the
credit card information 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. This will
allow you to repay your overpayment with your credit card. 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. If you want more
information about this, you may call or write any Social Security office.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government
agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Social Security offices. If you want to learn more about
this, contact any Social Security office.
This information collection meets the clearance requirements of 44 U.S.C. section
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management
Budget control number. We estimate that it will take you about 6 minutes to read the
instructions, gather the necessary facts, and answer the questions.