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

Form Approved

Social Security Administration

OMB No. 0960-0019

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 STATEMENT:
Collection and Use of Personal lnformatio
Sections 202(b) and (g) [42 .S.C. 402(b) and (g)] of the ocial· Security Act authorize us to c ect this information. We will use th information you
provide to confirm past an continuing entitlement to be efits and to determine whether such enefits are subject to suspension or rmination. The
information you provide
this form is voluntary. Ho ver, failure to provide all or part oft
requested information is cause for
to suspend your
benefit payments.
We rarely use the info ation you provide on this for for any purpose other than for the r sons explained above. However, w may use it for the
administration and in grity of Social Security progr
s.
·
· to another person or to another age cy in accordance with
approved routine u S, which include but are not li ited t
rd party or an agency to assist So . I Security in establishing
rights to Social S urity benefits and/or coverage· 2. To
•
the release of information from S cial Security records (e.g.,
to the Governme t Accountability Office, Gener Service
s Records Administration, and th Department of Veterans
rograms at the Federal, State,
d local level; and 4. To
Affairs); 3. To ake determinations for eligibili in simila
ty of Social Security programs
facilitate stati ical research, audit, or investi tive activit
ograms compare our records ith records kept by other
We may als use the information you provid in compute
Federal, St e, or local government agencie . Information from these matching pro ams can be used to establish or v ify a person's eligibility for
Federally- nded and administered benefit rograms for repayment of payments or elinquent debts under these progr s. The law allows us to do this
even if
u do not agree to it.
cords Notice entitled, Claims Fol
A com ete list of routine uses for this i ormation is available in our System of
additi nal information regarding this to' , and information regarding our progra s and systems, are available on-li
Soci Security office.

See revised
Pnvacy Act
Statement belOW.

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.socialsecuritv.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 1-800-325-0778). You may send comments on our time estimate above to: SSA. 6401 Security Blvd, Baltimore, MD
21235·6401. Sand !l!lff comments relating to our time estimate to this address, not the completed form.
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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.

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

DATE
CHILD
LEFT
YOUR
HOME

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:
AMOUNTS CONTRIBUTED

FIRST NAME OF CHILD

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 (08-2010) EF (08-2010) Destroy Pnor Ed1t10ns

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.

D

D

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.
-.,.--------=-----S_I_G_N_A_T_U_R_E_O_F_A_P_P_LI_C_A_N:-:cT.,...---:--:-.,..,-------1 DATE (Month, day, year)
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)
TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY
(include area code)

SIGN.

HERE
MAILING ADDRESS (Number and street, P. 0. 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 (XJ. 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 (08-2010) EF (08-2010)

2. SIGNATURE OF WITNESS

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

Privacy Act Statement
Collection and Use of Personal Information

Section 202 of the Social Security Act, as amended, authorizes us to collect this information. We
will use the information you provide to confirm past and continuing eligibility for benefits.
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 on your eligibility for
benefits, and could result in the loss of some benefits.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use it for the administration and integrity of our 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 us in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our 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 our programs (e.g., to the Bureau of the Census and
private entities under contract with us).
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.