Form SSA-760-F4 Certificate of Support

SOCIAL SECURITY ADMINISTRATION

TOE 4 2 0

CERTIFICATE OF SUPPORT
IThara is a time limitation tor the filing of this carlilsata. It a b u l d be filed prompUy.1

See Revised Privacy
Act Statement

OM6 No. 0 9 6 0 - 0 0 0 1

(Do not write in this space)

PRIVACY ACT PAPERWORK REDUCTION NOTICE: This form is authorized by sections 202lcl. l f l and rhl of the Social
Security AM. as amended 142 U.S.C. 402 lcl, 111, end lhl end section 334 of Public Lew 95-216. While it is not
mendatory for you to complete this lorm, failure to provide t h information requested may result in the deniel of your
Claim far Social Security benefits or to e reduction in yaL' benefit amount due to insufficient informstion. The information
provided will be used to determine whsthar you mast the ruppon requirements necessary for entitlement ro tha benefits
for which you are applying or the application of the excsption to government pension offset. The informetion may be
disclosed to another person or to another governmental agency er follows: 11 to enable a third pany or agency to assist
Social Securiry in establishing rights to Soclai Security benefits rndlor covarage; 21 to comply with Federal Lewr
requiring the release of information from Social Securoty records 1e.n.. m the General Accounring Office and the Veterans
AdmhirVarronl; and 31 to facilitate statislice1 research and audit activities necersery to assure the integrity and
improvement of the Social Security programs 1e.g.. ro me Bureau of m e Census andprivare concerns under conrracr ro
Social SecuriN)
PAPERWORK REDUCTION ACT: This informtion collection meat. the slaaransa requirements of 44 U.S.C. 53507, es amended by saction 2 of the
Paperwork Redustlon A n of 1996. Y w are not raqukad to answer thwa quwtions unless we dllplay a ralid OMce of Management and Budget control
number. We aatimata that will take you about 10 minuta. m read the instrudiona. gathar the necesaaw facts. and anawe, the questions.

See Revised Paperwork
Reduction Statment
/--

ENTER NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

(Herein referred to as

rhe "workern/

ENTER HIS IHERI SOCIAL SECURITY
NUMBER

--- I - - I - ---

PART I - IDENTITY
I intend that this certificate shall be considered as part of my application for insurance benefits which may be
payable to me under the provisions of Title II of the Social Security Act, as amended. I hereby certify that I
was receiving a t least one-half my support from the worker at the time specified in Item 8 of this Certificate
and submit the following information as proof of the facts.
1 . Enter your full name (Print or write clearly)

3. Enter your Social Security number

2. Enter your date of birth
(Month, Day and Year1

(If none, write ':Vone7')

r-.

- -- -4.

- -- -

( a ) Show your relationship t o the worker. (Husband, wife, widower, widow, mother, father, stepmother,
adopting father, etc.1 (If you indicate that you are the husband, wife, widower, or widow, Skip to item

9.1

I

5. If the worker has another living parent (other than yourself) enter the following

information regarding

other parent:

/In

FULL NAME

ADDRESS

RELATIONSHIP TO WORKER

mother, stepfarher, etc.1
I

6 . If you are a stepparent:
WHEN DID YOU MARRY THE WORKER'S FATHER OR MOTHER? WHERE DID THIS MARRIAGE TAKE PLACE?

7. If you are an adoptinq parent:
WHERE DID THIS ADOPTION TAKE PLACE?

WHEN DID YOU ADOPT THE WORKER?

Form SSA-760-F4 11 1-19831 IEF- 6120011

1.

(Father,

the

PART II - SUPPORT
MONTH

8.

DAY

YEAR

QUESTIONS 9 THROUGH 1 9 APPLY TO YOUR INCOME AND
SUPPORT FOR THE 12-MONTH PERIOD ENDING:
I

This form must be filed not later than

. .. .

....

DATE

AMOUNT

9. Enter the total amount of the worker's income during the 12-month period
shown in item 8.
I

I

10. (a) Did you o w n the dwelling in which you lived during the 12-month period
shown in item 8?

I

yes

No

(If "Yes, " g o on to item I I . If "No, " enter below the name and relationship o f the person who
owned the dwelling in which you lived and complete (bl a n d if appropriate, (c/ a n d id/./
NAME OF OWNER

RELATIONSHIP TO YOU /If none, write "None. "J
I

(b) Did you pay either rent or all the costs of maintaining the property (such as
repairs, mortgage, taxes, etc.)?

yes

(If "No, answer I c l a n d Id/./
I (If 'Yes, " skip (c/ a n d (d/ and g o to item I I )
I (c) List below each person who paid the rent or the costs of maintaining the property,

NO

-

"

-

for, and h o w much:

I

PERSON WHO PAID

what each paid

I

ITEM PAID FOR

AMOUNT

S

I(d) What was the monthly rental value of the house?

IS

I

Enter the following about the worker and any other person who lived with you or who contributed t o the
support of your household during the 12-month period shown in item 8. Include contributions for support,
payments for room and board, household expenses, clothing, insurance and medical expenses, gifts, etc.
NAME

I

RELATIONSHIP
TO YOU

I

DATES EACH
LIVED WITH
YOU

TOTAL AMOUNT
CONTRIBUTED
BY EACH

DATES
EACH CONTRIBUTED

2.

DATE

AMOUNT

S

S

S

$

S

$

S

$

12. If any of the contributions t o you stopped before the end of the period, explain why:

Form SSA-760-F4 11 1-19831 IEF- 6/20011

DATE AND AMOUNT OF
LAST CONTRIBUTION

-

1. -.
3 ,-, Did you furnish room and board t o anyone who lived with you during the 1 2 month period shown in

item 8?
Yes (If "Yes,

"

complete lbl.)

No (If
"No, " g o on to item 141

PERSON TO WHOM YOU FURNISHED
ROOM AND BOARD

COST OR ESTIMATED COST
OF ROOM AN0 BOARD IMONTHLYI

DATES FURNISHED

14. (a) Did you receive any income during the 12-month period shown in item 8 from any of the sources
shown below?
Yes (If
"Yes,

"

complete lbl below.)

"No, " go on to item 15.1
No (If
OATE YOU LAST RECEIVED INCOME
AN0 AMOUNT

(b)
INCOME

SOURCE

DATE

I

AMOLINT

Wages, salary, commissions, etc. (Show gross amounts before
deductions for taxes, FICA contributions, insurance, etc.)
fi

Pensions, annuities, insurance (including Social Security
benefits)

S

5

Stocks, bonds, securities, etc.

S

S

15. Did you or any member of the household receive any kind of public or private aid during the 12-month
~ e r i o dshown in item 8?

I

Yes (If
"Yes, "give the f o l l ~ w i n ginformation.)
(Include payments for room and board, for
household expenses, for clothing, for medical
expenses, etc.)
NAME OF PERSON FOR WHOM
AID WAS GIVEN

No (If
'No, " g o on to item 16.)

TOTAL
AMOUNT CONTRIBUTED
BY EACH

NAME AND

DATE AN0 AMOUNT
OF LAST CONTRIBUTION

DATE

S

, -.

AMOUNT

S

-

shown i n item 8.
TOTAL DEPOSITS MADE
DURING PERIOD

OWNERlSl OF ACCOUNT

L

TOTAL WITHDRAWALS
DURING PERIOD

17. Give the nature and amount of any other funds which were used for support (or saved) during the
12-month period shown in item 8.
-

I

Form SSA-760-F4 11 1-19831 (EF- 6120011

3.

p~

$
$

19. State any additional facts which you believe tend t o show that you were receiving at least one-half of
your support from the worker during the period shown in item 8.

REMARKS: lrhh space is for more detaikd answsrs m the above pvcrfionr, if necerrery. If you need more space, anach a separate sheer1
'4

.
.

I know that anvona rvho mabaa or cause. to be made a fabe rmtamnt w reDra.antation of material fact in en e~disation
or for ura in determinina
d t to
..
.a r i.
payment under the Social Sesudh Act corna ulme punlah.bl@undsr Fadsral law by Rna. inpriaonment or both. I aMrm thst all information I have given in
this d
u
n~
i.t m a.
.
.o c
~
. .~ ~
~~~

~

~

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SIGNATURE OF APPLICANT

SIGNATURE IfirEt name, middle initial, last nemel
[Write in ink1

=IGN
HERE

DATE (Month, day, year)
TELEPHONE NUMBER (Area Code)

MAILING ADDRESS /Number and street, Apt. No., P.O. BOX, or RuralRoutel

CITY AND STATE

ZIP CODE

ENTER NAME OF COUNTY lit any1 IN WHICH
YOU NOW LIVE

Witnesses are only required if this application has been signed by mark [ X I above. If signed by mark (XI, two witnesses
to the signing who know the applicant making the request must sign below, giving their full addresses.
2. SIGNATURE OF WITNESS

1. SIGNATURE OF WITNESS

I

ADDRESS (Number and street, City, Srate andZIP Codel

Form SSA-760-F4 (1 1-1983) IEF- 6120011

ADDRESS (Number and street, City, Stare andZIP Codel

4.

'U.S. Gorernmenl Prmnt,ng OFile Typeapplication/pdfFile Modified2010-01-04File Created2007-01-09