Form SSA-1425 REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYME

Form Approved
OMB No. 0960-0073

SOCIAL SECURITY ADMINISTRATION

REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT
USE THIS FORM WHEN THERE IS A CHANGE TO BE REPORTED. ONLY COMPLETE THE ITEM(S) THAT HAVE CHANGED.
PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
You should include the letter or letter and number A, B, B2 C, C1,
D, E, F, or H.
Your report cannot be processed without the correct claim number.

LETTER

DO YOU GET SSI BENEFITS? (Check one)
1.

CHANGE OF ADDRESS (Print new address at bottom)
If Social Security sends your payments to your financial organization,
do you want this to continue?

YES

NO

YES

NO

2.

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2009?
If you attain full retirement age (FRA) in 2009, your exempt amount is $37,680 ($3,140 a
month) for the months before the month you attain FRA. If you attain FRA in 2010 or
2a) MONTH AND YEAR
later, your exempt amount is $14,160 ($1,180).
a. I am working for wages of more than $1,180 a month (under FRA
COMPLETE BOTH
BOXES
in 2009) or $3,140 a month (if year of FRA attainment) or performing
2b) AMOUNT
substantial services in self-employment beginning with the month of_ _ _ _ _ _ _
$
b. I estimate that my total earnings for this taxable year will be
3a) MONTH AND YEAR
3.
STOPPING WORK OR LIMITING EARNINGS:
a. The last month I worked for wages of more than $1,180 (under FRA in 2009) or
$3,140 (if year of FRA attainment) or performed substantial services in
COMPLETE
self-employment was
3b) AMOUNT
BOTH BOXES

$

b. I estimate that my total earnings for this taxable year will be
4.

CHANGE IN ESTIMATE:
I estimate that my total earnings for this taxable year will be

5.

CHECK if you are self-employed, an officer of a corporation, or related to an
officer of a corporation.

6.

DEATH

7.

DATE OF DEATH:

9.

AMOUNT

$

DIVORCE

8.

DATE OF DIVORCE:

MARRIAGE (Place of Marriage) (City, County & State)

ANNULMENT
DATE OF ANNULMENT:

DATE OF MARRIAGE (MO., DAY, YR.) PRINT NEW LAST NAME

CHECK if spouse is now receiving Social Security benefits
IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S NAME SPOUSE'S CLAIM NUMBER

LETTER

10.

GOING OUTSIDE THE U.S.
FOR 30 CONSECUTIVE
DAYS OR LONGER

11.

CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR
CARE OR OTHERWISE CHANGED ADDRESS.

DATE LEFT YOUR CARE

12.

CONFINEMENT OR IMPRISONMENT
Confinement in a jail, prison, or other penal institution or correctional facility, based on a
conviction. Confinement in an institution by court order as a result of certain criminal cases.

DATE OF CONFINEMENT
(MONTH, DAY, YEAR)

13.

GOVERNMENT PENSION OR ANNUITY
a. I began receiving a government pension or annuity from the Federal
government or any State or any political subdivision or my present
payments have changed beginning with the month of

13a) MONTH AND YEAR

NAME OF COUNTRY TO WHICH GOING

DATE GOING

DATE EXPECT TO RETURN

13b) MONTHLY AMOUNT

$

COMPLETE BOTH BOXES

b. The amount of government pension or annuity I receive is or has been changed to
14.

BEGINNING DATE ENDING DATE

RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT
AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR
ANNUITY, STOPPED.

MONTH/YEAR

SIGNATURE OF PERSON MAKING THIS REPORT

DATE SIGNED

NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE

IS THIS A NEW ADDRESS?

Yes
CITY, STATE

MONTH/YEAR

ZIP CODE

Form SSA-1425 (05-2010) Destroy Prior Editions EF (05-2010)

No

NAME OF COUNTRY, IF ANY, IN
WHICH YOU LIVE

TELEPHONE NUMBER WHERE WE CAN REACH YOU
(INCLUDE AREA CODE)

PRIVACY ACT STATEMENT

HOW TO REPORT
There are three ways to report:
1. PHONE Social Security and explain the change.
Telephone Number (

(Area Code)

)

2. VISIT Social Security
3. MAIL this form to Social Security. Make sure you fill in:
—• NAME of person(s) the report is about

• The correct CLAIM NUMBER under which the
benefits are payable

• Whether the person(s) also receives SSI or Black
Lung benefits.
• WHAT is being reported
• DATE it happened
• Your SIGNATURE and ADDRESS
If you mail your report, please use this reporting form and send
it to the nearest Social Security office.
NOTE:

See Revised
Privacy Act
Sections 202, 203, and 205 of the Social Security Act, as amended
Statement
(42 U.S.C. 402, 403, and 405) authorizes us to collect this
Collection and Use of Personal Information

REMEMBER TO TELL US WHEN YOU MOVE,
EVEN IF YOUR MAILING ADDRESS FOR
CHECKS HAS NOT CHANGED.

WHAT TO REPORT
The law Sections 202, 203, and 205 of the Social Security Act,
as amended (42 United States Code 402, 403, and 405.)
required you to promptly report certain changes in your
circumstances which could affect your continuing eligibility to
benefits or your benefit amount. The kinds of changes you must
report to Social Security are listed on the reverse side of this
form. The booklet, "Your Social Security Rights and
Responsibilities, "tells more about reporting changes. If you do
not have this booklet or if you want help in making a report,
get in touch with any Social Security office. The people there
will be glad to help you.

FAILURE TO REPORT
If you do not report changes in your circumstances, you
may not be paid some, or all, of the benefits due you. Or,
you may be overpaid, in which case, you will have to pay
back any benefits you received that were not due you.
If you hide or do not report a change with the intent to
fraudulently get more benefits or benefits not due you, you
may be fined, imprisoned, or both per Section 208 of the
Social Security Act.

information. We will use the information you provide to assist us in
determining your continuing eligibility to benefits or your benefit
amount. The information you provide on this form is voluntary.
However, failure to provide all or part of the requested information
could prevent us from making an accurate and timely decision on your
claim or could result in the loss of benefits.
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 or administered benefit
programs and for repayment of payments or delinquent debts under
these programs.
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
Social Revised
Security office.
at www.socialsecurity.gov or at your localSee

Paperwork
Reduction
PAPERWORK REDUCTION
ACT Act
Paperwork Reduction Act Statement - This information
collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by Section 2 of the Paperwork
Reduction Act of 1995. You are 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 5 minutes to read the instructions, gather the
necessary 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.

Use this form only when there is a change to report to Social Security
Form SSA-1425 (05-2010) EF (05-2010)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Sections 202, 203, and 205 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to assist us in determining your
continuing eligibility to benefits or your benefit amount.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision, or could result in the
loss of benefits.
We rarely use the information you supply for any purpose other than to determine your
continuing eligibility to benefits or your benefit amount. 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 and 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 and improvement of Social Security programs (e.g., to the Bureau of the
Census).
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 or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice
entitled, Claims Folders Systems, 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 your local 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 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. 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 21235-0001. Send only comments relating to our time
estimate to this address, not the completed form.