Form SSA-4-BK, Application for Social Security Benefits Instructions

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This form contains 242 fields organized into 1 section. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Form SSA-4-BK (05-2023) U F. Use (04-2020) U F until Stock Is Exhausted. Social Security Administration. Application for Social Security Benefits Child's Insurance Benefits. O M B Number 0960-0010. Page 1 of 9. With this application, you are applying on behalf of the child or children listed in item 3 below for all insurance benefits for which they may be eligible under Title 2 (Federal Old-Age, Survivors and Disability Insurance) of the Social Security Act as presently amended. If you are applying on your own behalf, answer the questions on this form with respect to yourself. If you are applying for benefits based on the earnings record of a deceased worker, this may also be considered an application for survivors benefits under the Railroad Retirement Act and for Veterans Administration payments under Title 38, U S C Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under Title 38) Text
(Do not write in this space). Life Claim CheckBox
Death Claim CheckBox
1. ay Print name of Wage Earner or Self-Employed person (herein referred to as the "worker"). FIRST NAME, MIDDLE INITIAL, LAST NAME Text
1. b PRINT Worker's Social Security number Text
2 ay PRINT your name (unless you are the Worker). FIRST NAME, MIDDLE INITIAL, LAST NAME Text
2 b PRINT your Social Security number Text
Part 1 - Information about the worker's children 3. The Worker's children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including step grandchildren) may be eligible for benefits based on the earnings record of the Worker. For a living Worker, the information below applies to this month or to any of the past 12 months. For a deceased Worker, the information below applies to the date of death or for any period since the Worker's death. Below is a table with 6 rows and 10 columns. Column headers are labeled as column one List below all children who are: bullet Under age 18. bullet Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time. bullet Age 18 or older with a disability that began before age 22. Full Name of child. column 2 Date of Birth (M M/D D/Y Y Y Y). column 3 Check (X) if child is 17 and a half or older is: Student, COLUMN 4 Check (X) if Child is 17 and a half or older is: disabled column 5 Check (X) the Column That Shows Child's Relationship to Worker Natural; COLUMN 6 Check (X) the Column That Shows Child's Relationship to Worker Adopted; COLUMN 7 Check (X) the Column That Shows Child's Relationship to Worker Stepchild; COLUMN 8 Check (X) the Column That Shows Child's Relationship to Worker Dependent Grandchild; COLUMN 9 Check (X) the Column That Shows Child's Relationship to Worker Other column 10 Child's Social Security Number Row 1. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
Row 2. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
Row 3. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
Row 4. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
Row 5. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
Row 6. Full Name of Child who is Under age 18, Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time, or age 18 or older with a disability that began before age 22 Text
Date of Birth (M M/D D/Y Y Y Y) Text
Check if child is 17 and a half or Older and is a Student CheckBox
Disabled CheckBox
Check the Column That Shows Child's Relationship to Worker. Natural CheckBox
Adopted CheckBox
Stepchild CheckBox
Dependent Grandchild CheckBox
Other CheckBox
CHILD'S SOCIAL SECURITY NUMBER Text
If you do not wish to be payee for any child or dependent grandchild named above, list the child's name and address in "remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits. 4. If any children in item 3 are stepchildren of the Worker, enter the date the Worker married the natural parent. M M/D D/Y Y Y Y Text
5 ay Is there a legal representative (guardian, conservator, curator, etc.) for any of the children in item 3? Yes (If "Yes," complete (b) and (c).) CheckBox
No (If "No," go on to item 6.) CheckBox
Page 2 of 9. 5. b Write the following information about the legal representative(s): NAME (First name, middle initial, last name) Text
Address Text
telephone number (include area code) Text
5 c Briefly explain the circumstances which led the court to appoint a legal representative Text
6. Are you the natural or adoptive parent of the person(s) for whom you are filing? Yes CheckBox
No CheckBox
7. Have any children in item 3 ever been adopted by someone other than the Worker? Yes CheckBox
No CheckBox
If "Yes," enter the following information): This is a Table with 3 columns and 2 rows. Column headers are Name of Child, Date of Adoption, and Name of Person Adopting. Row 1. Name of child Text
Date of Adoption Text
Name of Person Adopting Text
Row 2. Name of child Text
Date of Adoption Text
Name of Person Adopting Text
8 Are all the children in item 3 now living in the same household with you? Yes CheckBox
No (If "No," enter the following information about each child not living with you. If uncertain as to the whereabouts of any of these children, explain in "Remarks".) CheckBox
This is a table with 3 columns and 4 rows. Column headers are Name of Child Not Living With You, Person with whom child now lives name and address, and the Relationship to Row 1. Name of Child Not Living With You Text
Person With Whom Child Now Lives. Name and Address Text
Relationship to Child Text
Row 2. Name of Child Not Living With You Text
Person With Whom Child Now Lives. Name and Address Text
Relationship to Child Text
Row 3. Name of Child Not Living With You Text
Person With Whom Child Now Lives. Name and Address Text
Relationship to Child Text
Row 4. Name of Child Not Living With You Text
Person With Whom Child Now Lives. Name and Address Text
Relationship to Child Text
9 Has any child in item 3 ever been married? Yes (If "yes", enter the information requested below.) CheckBox
No CheckBox
name of child Text
date of marriage (M M/D D/Y Y Y Y) Text
how marriage ended (if still married, write "not ended") Text
date marriage ended (M M/D D/Y Y Y Y) Text
Page 3 of 9. If you are applying ONLY for a child age 18 or over who is disabled, omit items 10 through 13. In all other cases, answer items 10 through 13. EARNINGS INFORMATION FOR LAST YEAR (Do not complete if the Worker died this year) 10. ( ay). Did any child in item 3 earn more than the exempt amount last year? Yes (If "Yes," answer (b.) CheckBox
No (If "No," go on to item 11.) CheckBox
10b. Below is a table with 3 columns and 3 rows. Column headers are NAME OF CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR, TOTAL EARNINGS OF CHILD, and LIST EACH MONTH THAT CHILD DID NOT EARN MORE THAN $ blank line IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT. Amount child did not earn more than in wages Text
Row 1. Name of child who earned over the exempt amount last year Text
TOTAL EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD DID NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 2. NAME OF CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR Text
TOTAL EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD DID NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 3. NAME OF CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR Text
TOTAL EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD DID NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
EARNINGS INFORMATION FOR THIS YEAR 11. (ay) Do you expect the total earnings of any child in item 3 to be more than the exempt amount this year? (Count all earnings beginning with the first of this year and all anticipated earnings through the end of this year.) Yes (If "Yes," answer (b.) CheckBox
No (If "No," go on to item 12.) CheckBox
11b. This is a table with 3 columns and 3 rows. Column headers are NAME OF CHILD WHO EXPECTS TO EARN OVER THE EXEMPT AMOUNT THIS YEAR, EXPECTED EARNINGS OF CHILD, and LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD DID NOT OR WILL NOT EARN MORE THAN dollar blank line IN WAGES AND DID NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT. Amount child did not or will not earn more than in wages Text
Row1. name of child who expects to earn over the exempt amount this year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD DID NOT OR WILL NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 2. Name of CHILD who expects to earn over the exempt amount this year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD DID NOT OR WILL NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 3. Name of CHILD who expects to earn over the exempt amount this year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD DID NOT OR WILL NOT EARN MORE THAN dollar (amount entered above) IN WAGES AND DID NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Complete item 12 ONLY if any child is now in the last 4 months of the child's taxable year (September, October, November, and December, if the taxable year is a calendar year). EARNINGS INFORMATION FOR NEXT YEAR 12. ( ay) Do you expect the total earnings of any child in item 3 to be more than the exempt amount next year? Yes (If "Yes," answer (b.) CheckBox
No (If "No," go on to item 13.) CheckBox
12(b) This is a table with 3 columns and 3 rows. Column headers are Name of child who expects to earn over the exempt amount next year, Expected Earnings of child, and List each month that child will not earn more than $ blank in wages and will not perform substantial services in self-employment. Amount child will not earn more than in wages Text
Row 1. Name of child who expects to earn over the exempt amount next year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD WILL NOT EARN MORE THAN $ (Amount entered above) in WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 2. Name of child who expects to earn over the exempt amount next year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD WILL NOT EARN MORE THAN $ (Amount entered above) in WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
Row 3. Name of child who expects to earn over the exempt amount next year Text
EXPECTED EARNINGS OF CHILD Text
LIST EACH MONTH THAT CHILD WILL NOT EARN MORE THAN $ (Amount entered above) in WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT Text
13. If any of the children for whom you are filing uses a fiscal year (one that does not end on December 31), print here the name of the child and the month the fiscal year ends. Name of child and month fiscal year ends Text
Complete items 14 and 15 ONLY if the Worker is living. Otherwise, go on to item 16. 14. If any children in item 3 are children adopted by the Worker, print below the name of each such child and the date of adoption by the Worker. This is a table with 2 columns and 4 rows, Column headers are Name of Adopted Child and Date of Adoption. Row 1. Name of adopted child Text
DATE OF ADOPTION Text
Row 2. Name of adopted child Text
DATE OF ADOPTION Text
Row 3. Name of adopted child Text
DATE OF ADOPTION Text
Row 4. Name of adopted child Text
DATE OF ADOPTION Text
Page 4 of 9. 15 Have all of the children in item 3 lived with the Worker during each of the last 13 months (counting the present month)? Yes CheckBox
No (If "No," enter the information requested below) CheckBox
This is a table with 4 columns and 2 rows. Column Headers are Name of child who did not live with the worker in each of the last 13 months, List each month in which this child did not live with the worker, and Person with whom the child lived Name and Address and person with whom child lived relationship to child. Row 1. NAME OF CHILD WHO DID NOT LIVE WITH THE WORKER IN EACH OF THE LAST 13 MONTHS Text
LIST EACH MONTH IN WHICH THIS CHILD DID NOT LIVE WITH THE WORKER Text
PERSON WITH WHOM CHILD LIVED. NAME AND ADDRESS Text
PERSON WITH WHOM CHILD LIVED. RELATIONSHIP TO CHILD Text
Row 2. NAME OF CHILD WHO DID NOT LIVE WITH THE WORKER IN EACH OF THE LAST 13 MONTHS Text
LIST EACH MONTH IN WHICH THIS CHILD DID NOT LIVE WITH THE WORKER Text
PERSON WITH WHOM CHILD LIVED. NAME AND ADDRESS Text
PERSON WITH WHOM CHILD LIVED. RELATIONSHIP TO CHILD Text
16. If any of the children in item 3 are within 2 months of age 65 or older, blind or disabled, do you want to file on their behalf for Supplemental Security Income? Yes CheckBox
No CheckBox
PART 2 - INFORMATION ABOUT THE DECEASED. Complete items 17 through 24 only if the Worker is deceased. 17. (ay) Print date of birth of Worker. M M/D D/Y Y Y Y Text
18 (b) Print Worker's name at birth if different from item 1 (ay) Text
18 (ay) Print date of death. M M/D D/Y Y Y Y Text
19 (b) Print place of death City and State Text
19. Print the name of the state or foreign country where the Worker had a fixed, permanent home at the time of death. State or foreign country Text
20. Did the Worker work in the railroad industry for 5 years or more? Yes CheckBox
No CheckBox
21. (ay) Did the worker have social security credits (for example, based on work or residence) under another country's social security system? Yes (If "Yes,"answer (b).) CheckBox
No (If "No," go on to item 22.) CheckBox
(B) List the countries Text
22 (ay) Did the worker have wages or self-employment income covered under Social Security in all years from 1978 through last year? Yes (If "Yes", skip to item 23.) CheckBox
No (If "No," answer (b).) CheckBox
(b) List the years from 1978 through last year in which the worker did not have wages or self-employment income covered under Social Security Text
Answer item 23 ONLY if death occurred within the last 2 years. 23. (ay) How much did the Worker earn from employment and self-employment during the year of death? Amount $ blank Text
25. (b) How much did the Worker earn the year before death? Amount $ blank Text
Page 5 of 9. 24. Check if applicable: I am not submitting evidence of the deceased's earnings that are not yet on their earnings record. I understand that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid with full retroactivity CheckBox
Answer item 25 ONLY if the Worker died prior to age 66 and within the past 4 months. 25. (ay) Was the Worker unable to work because of a illnesses, injuries or conditions at the time of death? Yes (If Yes, answer (b)) CheckBox
no CheckBox
(b) Enter the date the Worker first became unable to work. M M/D D/Y Y Y Y Text
26. Were all the children in item 3 living with the Worker at the time of death? Yes CheckBox
No (If "No," enter the following information) CheckBox
This is a table with 3 columns and 2 rows. Column headers are name of Child not living with the worker, person with whom child was living name and address, and relationship to child. Row 1. NAME OF CHILD NOT LIVING WITH THE WORKER Text
PERSON WITH WHOM CHILD WAS LIVING. NAME AND ADDRESS Text
PERSON WITH WHOM CHILD WAS LIVING. RELATIONSHIP TO CHILD Text
Row 2. NAME OF CHILD NOT LIVING WITH THE WORKER Text
PERSON WITH WHOM CHILD WAS LIVING. NAME AND ADDRESS Text
PERSON WITH WHOM CHILD WAS LIVING. RELATIONSHIP TO CHILD Text
REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.) Text
Page 6 of 9. Continued Remarks Text
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment. Signature of Applicant SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink). A Wet Signature is required for this form. Please complete the form, print, and sign Text
Date (M M/D D/Y Y Y Y) Text
Telephone Number(s) at Which You May be Contacted During the Day Text
Direct Deposit Payment Information (Financial Institution) Routing Transit Number Text
Account Number Text
Checking CheckBox
Savings CheckBox
Enroll in Direct Express CheckBox
Direct Deposit Refused CheckBox
Applicant's Mailing Address (Number and street, Apartment Number, P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.) Text
City and State Text
ZIP Code Text
County (if any) in which you now live Text
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant must sign below giving their full addresses. Also, print the applicant's name in the signature block 1. Signature of Witness. Ay Wet Signature is required for this form. Please complete the form, print, and sign Text
Address of first Witness (Number and Street, City, State, and ZIP Code) Text
2. Signature of Witness. Ay Wet Signature is required for this form. Please complete the form, print, and sign Text
Address of second Witness (Number and Street, City, State, and ZIP Code) Text
Page 7 of 9. Privacy Act Statement Collection and Use of Personal Information Section 202(d) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed. We will use the information to determine eligibility for monthly benefits or insurance coverage and to authorize payments to the child(children) of retired, disabled, or deceased workers. We may also share your information for the following purposes, called routine uses: bullet To Federal, State, or local agencies for administering cash or non-cash income or health maintenance programs; and bullet To a contractor or another Federal agency, as necessary for the purpose of assisting the Social Security Administration in the efficient administration of its programs. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of additional routine uses is available in our Privacy Act System of Records Notice (S O R N) 60-0089, entitled Claims Folders System, as published in the Federal Register (F R) on April 1, 2003, at 68 F R 1 5 7 8 4. Additional information, and a full listing of all of our S O R Ns, is available on our website at w w w . s s ay . g o v / privacy Text
Link to w w w.ssa.gov/privacy web page Button
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 12 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSAy's website at w w w . social security . g o v. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSAy, 6401 Security Blvd, Baltimore, MD 2 1 2 3 5 - 6 4 0 1. Send only comments relating to our time estimate to this address, not the completed form Text
Link to w w w.ssa.gov/representation web page Button
Page 8 of 9. RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY CHILD'S INSURANCE BENEFITS. TELEPHONE NUMBER(S) TO CALL IF YOU HAVE A QUESTION OR SOMETHING TO REPORT. BEFORE YOU RECEIVE A NOTICE OF AWARD Text
TELEPHONE NUMBER(S) TO CALL IF YOU HAVE A QUESTION OR SOMETHING TO REPORT AFTER YOU RECEIVE A NOTICE OF AWARD Text
SSA OFFICE Text
DATE CLAIM RECEIVED Text
Your application for Social Security benefits on behalf of the child(ren) named below has been received. You will be notified by mail as soon as a decision is made on your claim. You should hear from us within blank days after you have given us all the information we requested. Number of days recipient will hear from SSA Text
Some claims may take longer if additional information is needed. In the meantime, if you or any child(ren) changes address, or if there is some other change that may affect your claim, you or someone for you should report the change. The changes to be reported are listed on page 9. Always give us your claim number when writing or telephoning about your claim. If you have any questions about your claim, we will be glad to help you. Below is a table with 2 columns and 4 rows. Column headers are Claimant and Social Security Claim Number. Row 1. Claimant Text
SOCIAL SECURITY CLAIM NUMBER Text
Row 2. Claimant Text
SOCIAL SECURITY CLAIM NUMBER Text
Row 3. Claimant Text
SOCIAL SECURITY CLAIM NUMBER Text
Row 4. Claimant Text
SOCIAL SECURITY CLAIM NUMBER Text
WORKER'S NAME (If surname differs from name of claimant(s).) Text
Page 9 of 9. CHANGES TO BE REPORTED AND HOW TO REPORT. FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID AND IN POSSIBLE MONETARY PENALTIES. Bullet. You or any child changes mailing address for checks or residence. To avoid delay in receipt of checks, you should ALSO file a regular change of address notice with your post office. Bullet. Any child's citizenship or immigration status changes. Bullet. Any beneficiary goes outside the U.S.A. for 30 consecutive days or longer. Bullet. Any beneficiary dies or becomes unable to handle benefits Text
work changes - on your application you told us BLANK expected total earnings for blank to be dollar blank. Name of Child Text
Year Text
Dollar amount of expected total earnings Text
Name of child Text
Is Earning CheckBox
is not earning CheckBox
wages of more than dollar BLANK a month. Dollar amount child is or is not earning in a month Text
Blank is or is not self-employed and rendering substantial services in a trade or business. Name of Child Text
is self-employed CheckBox
is not self-employed CheckBox
(Report AT ONCE if this work pattern changes.). Bullet. Custody Change - Report if a child for whom you are filing or who is in your care dies, leaves your care or custody, or changes address. Bullet. The child age 13 or older has an unsatisfied felony or arrest warrant for more than 30 continuous days for flight to avoid prosecution or confinement, escape from custody, or flight-escape Text
Bullet. A student, age 18 or over, stops attending school, reduces school attendance below full-time, changes schools, or is paid by an employer to attend school. Bullet. If the worker and stepchild's parent divorce. Benefits are not payable to a stepchild beginning with the month after the month the worker and the stepchild's parent divorce. Promptly return any benefit payment received on behalf of the stepchild for the months after the month the divorce becomes final. Bullet. The child is confined for more than 30 continuous days to a jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by a court order in connection with a crime. Bullet. Change in Marital Status - Marriage, divorce, or annulment of marriage. You must report marriage even if you believe that an exception applies. Bullet. Disability Applicants - In addition to the applicable reporting requirements listed above: 1. The disabled adult child returns to work (as an employee or self-employed) regardless of amount of earnings. 2. The disabled adult child's condition improves. An agency in your State that works with us in administering the Social Security disability program is responsible for making the disability decision on the child's claim. In some cases, it is necessary for them to get additional information about the child's condition or to arrange for the child to have a medical examination at Government expense Text
how to report. You can make your reports online, by telephone, mail, or in person, whichever you prefer. If you are awarded benefits and one or more of the above change(s) occur, you should report by: Bullet. Visiting the section "My Social Security" at our web site at w w w . social security . g o v; Bullet. Calling us TOLL FREE at 1 - 800 - 7 7 2 - 1 2 1 3; Bullet. If you are deaf or hearing impaired, calling us TOLL FREE at T T Y 1 - 800 - 3 2 5 - 0 7 7 8; or Bullet. Calling, visiting, or writing your local Social Security office at the phone number and address shown on your claim receipt. For general information about Social Security, visit our web site at w w w . social security . g o v. For those under full retirement age, the law requires that a report of earnings be filed with SSAy within 3 months and 15 days after the end of any taxable year in which the child earns more than the annual exempt amount. You may contact SSAy to file a report for the child. Otherwise, SSAy will use the earnings reported by the child's employer(s) and the child's self-employment tax return (if applicable) as the report of earnings required by law, to adjust benefits under the earnings test. It is your responsibility to ensure that the information you give concerning the child's earnings is correct Text
Link to w w w.socialsecurity.g o v web page Button
Link to w w w.socialsecurity.g o v web page Button
You have reached the end of the form. If you tab out of this field you will return to the beginning of the form Text