Application for Child's Insurance Benefits Instructions (Current)

Form Approved
OMB No. 0960-0010

REPORTING RESPONSIBILITIES FOR CHILD'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID AND IN POSSIBLE MONETARY PENALTIES

♦

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.

♦

Any child's citizenship or immigration status changes.

♦

Any beneficiary goes outside
consecutive days or longer.

the

U.S.A.

for

30

Any beneficiary dies or becomes unable to handle
benefits.

♦

Work Changes - On your application you told us
expected total earnings
for

to be $

♦

♦ Disability Applicants - In addition to the applicable
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.

.

(Year)

(is)
(Name of Child)

wages of more than $

(is not) earning
a month.

(is)

(is not) self-

HOW TO REPORT

(Name of Child)

♦
♦

♦

The child is confined to jail, prison, penal institution or
correctional facility for conviction of a crime or confined
to a public institution by court order in connection with a
crime.
Change of Marital Status - Marriage, divorce, or
annulment of marriage of any child. You must report
marriage even if you believe that an exception applies.
reporting requirements listed above:

♦

(Name of Child)

♦

employed rendering substantial services in a trade or
business.

You can make your reports by telephone, mail, or in
person, whichever you prefer.

(Report AT ONCE if this work pattern changes)

If you are awarded benefits, and one or more of the above
change(s) occur, you should report by:

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.
The child age 13 or older has an unsatisfied warrant for
their arrest for a crime or attempted crime that is a
felony (or in jurisdictions that do not define crime as
felonies, a crime that is punishable by death or
imprisonment for a term exceeding 1 year).
The child age 13 or older has an unsatisfied warrant for
a violation of probation or parole under Federal or State
law.

♦

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.

♦

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 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.

Form SSA-4-INST (4-2006 EF (04 -2006)

Destroy Prior Editions

Page 1

♦

Calling us TOLL FREE at 1-800-772-1213

♦

If you are deaf or hearing impaired, calling us
TOLL FREE at TTY 1-800-325-0778; or

♦

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 www.socialsecurity.gov.
For those under full retirement age, the law
requires that a report of earnings be filed with SSA
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 SSA to
file a report for the child. Otherwise, SSA 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.

NOTICE ABOUT DOCUMENTS
We recommend that you keep all documents you submitted to us.
We are returning the documents you submitted with this claim.

Collection and Use of Information From Your Application - Privacy Act Notice/Paperwork Reduction Act Notice
The Social Security Administration is authorized to collect the information requested on this form under sections
202, 205 and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You do
not have to give us the requested information. However, if you do not provide the information, we will be unable to
make an accurate and timely decision concerning your entitlement or a dependent's entitlement to benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency for determining
eligibility for a government benefit or program, to a Congressional office requesting information on your behalf, to an
independent party for the performance of research and statistical activities, or to the Department of Justice for use in
representing the Federal government.
We may also use this information 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 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 10.5 - 15.0
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. 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.

Form SSA-4-INST (4 -2006 EF (04 -2006) Destroy Prior Editions

Page 2