Form SSA-783 Statement Regarding Contributions

TOE 250

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0020

STATEMENT REGARDING CONTRIBUTIONS
All items on this form requiring an answer must be answered or marked "Unknown."
PRIVACY ACT/PAPERWORK ACT NOTICE: This notice is given pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). The information requested on this form
is sought pursuant to the authority granted in Sections 202(d) and (h) of the Social Security Act. The information provided will be used to confirm entitlement
to such benefits. Other uses which may be made of the information are summarized below. While completion of this form is voluntary, failure to provide all or
any part of the requested information may be cause for denial of benefits. The information you furnish on this form may be disclosed by Social Security to
another person or to another governmental agency as follows for the following purposes: (1) to assist Social Security in establishing the right of an individual
to Social Security 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.
Computer Matching: 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.
Explanation 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 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778).
Send only comments on our time
estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

See Revised PRA Attached

PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

ENTER SOCIAL SECURITY NUMBER

I understand that information given by me will be used in connection with an application for insurance benefits payable
under the provisions of Title II of the Social Security Act, as amended, on the record of the wage earner or self-employed
person named above.
PRINT YOUR FULL NAME

RELATIONSHIP TO CLAIMANT

(FIRST NAME, MIDDLE INITIAL, LAST NAME)

PRINT NAME OF CLAIMANT

1.

RELATIONSHIP TO WAGE EARNER OR SELF-EMPLOYED PERSON

(a) Give the following information (for the period indicated below) about each person or agency who
contributed to the claimant's support.
FROM

TO

NAME AND ADDRESS OF
CONTRIBUTORS

RELATIONSHIP
TO
CLAIMANT

CONTRIBUTIONS
BEGAN
MO.
YR.

ENDED
MO.

YR.

HOW OFTEN
MADE

AVERAGE
AMOUNT OF
(Weekly, monthly CONTRIBUTION
or occasionally)

$
$
$
(b) Was there any break in contributions by any contributor within the period?
YES
If "Yes," give name of contributor, months in which no contributions were made, and reason:

NO

(c) If any contributions ended before the wage earner's or self-employed person's death or, if living, before
application was filed, give name of contributor and why he stopped:

(d) If other than cash was contributed, such as clothing, board or room, give the following information regarding
items supplied during the period in 1(a).
NAME OF CONTRIBUTOR

APPROXIMATE
VALUE

ITEMS CONTRIBUTED

$
$
(e) Give name and address of person or agency to which payments were made for claimant's support:

Form SSA-783 (08-2008) EF (08-2008)
Destroy prior editions

(Over)

2.

Yes

Did the claimant have wages or income of his or her own?
If "Yes, " how much per month?

No

$

IN WHICH MONTHS (Specify)

3.

(a) Is claimant a child who lived with more than one parent (natural, adopting or stepparent)?
Yes If "Yes" answer (b), (c) and (d) below.
No
If "No" go on to item 4.
(b) If both parents with whom child lived contributed to child's support,
did they use their monies as one household fund?
If "Yes," how much did each contribute to
the fund?

Yes

MOTHER

No

FATHER

$

$

(c) If their monies were not combined, what understanding did they have as to how much each would contribute
to the child's support?

NOTE: If such agreement was in writing, submit a copy.
(d) What was the monthly income of each?

MOTHER

FATHER

$
How did you learn of the facts you gave in questions 1, 2, and 3?

4.

$

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 PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)

SIGN
HERE

DATE (Month, day, year)

TELEPHONE NUMBER (Including Area Code)

X

MAILING ADDRESS (Number and street, Apt. No., 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 statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the person making the statement must sign below, giving their full
addresses.
1. SIGNATURE OF WITNESS

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

Form SSA-783 (08-2008) EF (08-2008)

2. SIGNATURE OF WITNESS

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

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 17
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). Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.