Form SSA-1372-BK-FC Student's Statement Regarding School Attendance

PRIVACY ACf/PAPERWORK ACf NOTICE

The Social Security Administration is authorized to collectinformation aboutschool attendance undersections 202(d)and205(a)
ofthe SocialSecurity Act, as amended (42 U.S.C. 402 and405). While completing this fonn is voluntary, failure to provide all
or part of this infonnation is causefor suspension of benefit payments. The infonnation on this fonn may be disclosed by the
SocialSecurity Administration to another personor agency for the following purposes: (I) to assistthe SocialSecurity
Administration in establishing the student's right to Social Security benefits, (2) to help with statistical research and audits
necessary to assure the integrity and improvement of the SocialSecurity programs, and (3) to comply with lawsrequiring or
allowing the exchange of infonnation between the SocialSecurity Administration and anotheragency. This infonnation will be
used to veritY full-time attendance in schooland to detenninecontinuing eligibility to studentbenefits.
We may also use the infonnation you give us whenwe match records by computer. Matching programs compare our records
with thoseof otherFederal, State,or localgovernment agencies. Manyagencies may usematchingprograms to find or prove
that a personqualities for benefits paid by the Federal government. The lawallows us to do this even if you do not agree to it.
Explanations about these andother reasons why infonnation you give us may be used or givenout are available in Social
Security offices. If you want to leam more about this, contact any SocialSecurity office.

PAPERWORK REDUC.TION ACT: 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
q~estions unless we display a valid Office of Management and Budget control number. We estimate that it
WIll take about II minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is 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: SSA,
6401 Security Blvd, Baltimore. MD 21235-6401. Send onlv comments relating to our time estimate to
this address, not the completedform.

Form SSA-1372-BK-FC (00-2007)

Page 6

PRIVACY ACTIPAPERWORK REDUCTION ACT NOITICE
The Social Security Administration is authorized to collect information about school attendance under sections 202{d) and 205(a)
of the Social Security Act, as amended (42 U.S.C. 402 and 405). While completing this form is voluntary, failure to provide all
or part of this information is cause for suspension ofbenefit payments. The information on this form may be disclosed by the
Social Security Administration to another person or agency for the following purposes: (1) to assist the Social Security
Administration in establishing your right to Social Security benefits, (2) to help with statistical research and audits necessary to
assure the integrity and improvement of the Social Security programs. and (3) to comply with laws requiring or allowing
exchanges of information between the Social Security Administration and another agency. This information will be used to
verify full-time attendance in school and to determine continuing eligibility to student benefits,
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 govemment. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you give 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.

PAPERWORK REDUCTION ACT: 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 11 minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is 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: SSA,

6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completedform.

Form SSA-1372-BK-FC (00-2007)
Page 8