Current SSA-1-INST

Form Approved
OMB No. 0960-0007

REPORTING RESPONSIBILITIES FOR RETIREMENT 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 change your 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.)

Your stepchild is entitled to benefits on your record
and you and the stepchild's parent divorce.
Stepchild benefits are not payable beginning with
the month after the month the divorce becomes
final.

Your citizenship or immigration status changes.

Custody Change — Report if a person for whom you
are filing, or who is in your care dies, leaves your
care or custody, or changes address.

You go outside the U.S.A. for 30 consecutive days
or longer.
Any beneficiary dies or becomes unable to handle
benefits.
Work Changes — On your application you told us
you expect total earnings for
to be
(Year)
$_____________.
You
than $

(are)

(are not) earning wages of more
a month.

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.

Change of Marital Status — Marriage, divorce,
annulment of marriage.
HOW TO REPORT
You can make your reports 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:
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

(Report AT ONCE if this work pattern changes)
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you
are confined to a public institution by court order in
connection with a crime.
You become entitled to a pension or annuity based
on your employment after 1956 not covered by
Social Security, or if such pension or annuity stops.
You have an unsatisfied warrant for your arrest for
a crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment
for a term exceeding 1 year.)
You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

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 you earn more than the annual exempt
amount. You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your 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 your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

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

Form SSA-1-INST (3-2006) EF (03-2006) Destroy prior editions

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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 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
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-1-INST (3-2006) EF (03-2006 )Destroy prior editions

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