SSA-781 (current)

Form Approved
OMB No. 0960-0019

Social Security Administration

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."
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.
NAME, ADDRESS,
How Long
DATE
TELEPHONE
NUMBER AND
From today
REASON CHILD
FULL NAME OF CHILD
CHILD
RELATIONSHIP
will the child LEFT YOUR HOME
LEFT YOUR be away
(TO CHILD) OF PERSON
HOME
WITH WHOM CHILD
from you?
IS NOW LIVING

2. (a) If you contribute to the support of any child named in item 1 above, give the following information:
FIRST NAME OF CHILD

AMOUNTS CONTRIBUTED

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 (2-2014) ef (2-2014)
Destroy Prior Editions

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3. State how often you do any of the things shown below for any child named in item 1.
FIRST NAME OF CHILD

VISIT

SEND
CLOTHING

MAKE OTHER
GIFTS

WRITE
LETTERS

4. Do you give the person or persons with whom the child or children have been placed
instructions for the care of such child or children?

OTHER
(DESCRIBE)

Yes

No

If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are
carried out.

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 APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, day, year)
Telephone Number(s) At Which You May Be
Contacted During The Day (include area
code)

MAILING ADDRESS (Number and street, 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 application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
Address (Number and street, City, State and Zip Code)
Form SSA-781 (2-2014) ef (2-2014)

Address (Number and street, City, State and Zip Code)

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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.
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.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 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.

Form SSA-781 (2-2014) ef (2-2014)

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