Form SSA-781 Certificate of Responsibility for Welfare Care of a Chil

Form Approved
OMB No. 0960-0019

Social Security Administration

See Revised Privacy
Act Statement

CERTIFICATE OF RESPONSIBILITY FOR WELFARE
AND CARE OF CHILD NOT IN APPLICANT'S CUSTODY
All items on this form requiring an answer must be answered or marked "Unknown."

PRIVACY ACT NOTICE/PAPERWORK ACT NOTICE: The information requested on this form is sought pursuant to the authority granted in 42
U.S.C. 402(b) and 402(g). The information provided will be used to confirm past and continuing entitlement to benefits and to determine whether
such benefits are subject to suspension or termination. While completion of this form is voluntary, failure to provide all or any part of the requested
information is cause for suspension of benefit payments. The information you furnish on this form may be disclosed by Social Security to another
person or to another governmental agency for the following purposes: (1) to assist Social Security in establishing the right of an individual to Social
Security coverage and/or benefits; (2) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
Social Security programs; and (3) to comply with Federal laws requiring the exchange of information between Social Security and another agency.
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.

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 10 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
completed form.
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER

See Revised
Paperwork Reduction
Act

I make this statement in support of my application for insurance benefits payable under Title II of the Social
Security Act, as amended.
1. Give the following information about all unmarried children of the above wage earner or self-employed person
who are not living with you and are: (a) under age 16, or (b) age 16 or over, with a disability that began before
age 22. Include natural children, adopted children, stepchildren, and dependent grandchildren or
step-grandchildren.
FULL NAME OF CHILD

2.

DATE
CHILD
LEFT
YOUR
HOME

How Long
From today will
the child
be away
from you?

REASON CHILD
LEFT YOUR HOME

NAME, ADDRESS, TELEPHONE
NUMBER AND RELATIONSHIP
(TO CHILD) OF PERSON
WITH WHOM CHILD
IS NOW LIVING

(a) If you contribute to the support of any child named in item 1 above, give the following information:
FIRST NAME OF CHILD

AMOUNTS CONTRIBUTED

HOW OFTEN YOU CONTRIBUTE

$
$
$
$
(b) If you are not contributing to the support of any child named in 1 above, give name of child and state why
you are not doing so.

Form SSA-781 (11-2009) EF (11-2009)

3.

State how often you do any of the things shown below for any child named in item 1.
FIRST NAME OF CHILD

4.

VISIT

SEND CLOTHING

MAKE OTHER
GIFTS

WRITE
LETTERS

OTHER
(DESCRIBE)

Do you give the person or persons with whom the child or children have been placed
Yes
No
instructions for the care of such child or children?
If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are
carried out.

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 or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
SIGNATURE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, day, year)

TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY
(include area code)

SIGN
HERE
MAILING ADDRESS (Number and street, P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

ENTER NAME OF COUNTY (IF ANY) IN WHICH YOU NOW
LIVE

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.
1. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-781 (11-2009) EF (11-2009)

2. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)

SSA will insert the following revised Privacy Act Statement into the
form at its next scheduled reprinting:
Certificate Of Responsibility For Welfare And Care Of Child Not In Applicant’s
Custody, Form SSA-781
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(b) and (g) [42 U.S.C. 402(b) and (g)] of the Social Security Act
authorize us to collect this information. We will use the information you provide to
confirm past and continuing entitlement to benefits and to determine whether such
benefits are subject to suspension or termination. The information you provide on this
form is voluntary. However, failure to provide all or part of the requested information
is cause for us to suspend your benefit payments.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records(e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs for repayment of payments or delinquent debts under these programs. The
law allows us to do this even if you do not agree to it.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at any Social Security
office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 10
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 SSA’s website at
www.socialsecurity.gov. 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 1800-325-0778). 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 completed form.