Form SSA-760-F4 Certificate of Support

SOCIAL SECURITY ADMINISTRATION

TOE 420

Form Approved
OMB No. 0960-0001

CERTIFICATE OF SUPPORT
(There is a time limitation for the filing of this certificate. It should be filed promptly.)
DO NOT WRITE IN THIS SPACE

Enter Name of Wage Earner or Self-Employed Person (Herein referred to as
the "worker")

Enter His (Her) Social Security Number

PART I - IDENTITY
I intend that this certificate shall be considered as part of my application for insurance benefits which may be payable to
me under the provisions of Title II of the Social Security Act, as amended. I hereby certify that I was receiving at least
one-half my support from the worker at the time specified in Item 8 of this Certificate and submit the following information
as proof of the facts.
1. Enter your full name (Print or write clearly)

2. Enter your date of birth (Month, Day, and Year)

3. Enter your Social Security number (If
none, write "None")

4. (a) Show your relationship to the worker. ( Husband, wife, widower, widow, mother, father, stepmother, adopting
father, etc.) (If you indicate that you are the husband, wife, widower, or widow, Skip to item 9.)
5. If the worker has another living parent (other than yourself) enter the following information regarding the other parent:
FULL NAME

AGE

ADDRESS

Relationship To Worker (Father,
mother, stepfather, etc.)

6. If you are a stepparent:
When Did You Marry The Worker's Father Or Mother?

Where Did This Marriage Take Place?

7. If you are an adopting parent:
When Did You Adopt The Worker?

Where Did This Adoption Take Place?

Form SSA-760-F4 (04-2014) EF (04-2014)

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PART II - SUPPORT
MONTH

8. QUESTIONS 9 THROUGH 19 APPLY TO YOUR INCOME AND
SUPPORT FOR THE 12-MONTH PERIOD ENDING:

This form must be filed not later than . . . . . . . .

DAY

YEAR

DATE

9. Enter the total amount of the worker's income during the 12-month period shown in
item 8.

AMOUNT

10. (a) Did you own the dwelling in which you lived during the 12-month period shown in
item 8?

Yes

No

(If "Yes," go on to item 11. If "No," enter below the name and relationship of the person who owned the
dwelling in which you lived and complete (b) and if appropriate, (c) and (d).)
NAME OF OWNER

RELATIONSHIP TO YOU (If none, write "None.")

(b) Did you pay either rent or all the costs of maintaining the property (such as repairs,
mortgage, taxes, etc.)?
(If "Yes," skip (c) and (d) and go to item 11)

Yes

No

(If "No," answer (c) and (d).)

(c) List below each person who paid the rent or the costs of maintaining the property, what each paid for, and
how much:
PERSON WHO PAID
AMOUNT
ITEM PAID FOR
$
$
$
$

(d) What was the monthly rental value of the house?

$

11. Enter the following about the worker and any other person who lived with you or who contributed to the support of
your household during the 12-month period shown in item 8. Include contributions for support, payments for room and
board, household expenses, clothing, insurance and medical expenses, gifts, etc.

NAME

Dates each
Total Amount
Relationship
Dates Each
Lived With
Contributed
To You
Contributed
You
By each
$

$

$

$

$

$

$

$

12. If any of the contributions to you stopped before the end of the period, explain why:

Form SSA-760-F4 (04-2014) EF (04-2014)

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Date and Amount
Of Last Contribution
DATE
AMOUNT

13. (a) Did you furnish room and board to anyone who lived with you during the 12 month period shown in item 8?
Yes (If "Yes," complete (b).)
(b)

PERSON TO WHOM YOU FURNISHED ROOM
AND BOARD

No (If "No," go on to item 14)
DATES
FURNISHED

COST OR ESTIMATED COST OF
ROOM AND BOARD (MONTHLY)

14. (a) Did you receive any income during the 12-month period shown in item 8 from any of the sources shown
below?
Yes (If "Yes," complete (b) below.)
No (If "No," go on to item 15.)
(b)

INCOME

SOURCE

DATE YOU LAST RECEIVED
INCOME AND AMOUNT
DATE

AMOUNT

Wages, salary, commissions, etc. (Show gross amounts before $
deductions for taxes, FICA contributions, insurance, etc.)
Pensions, annuities, insurance (including Social Security
$
benefits)

$

Stocks, bonds, securities, etc.

$

$

$

15. Did you or any member of the household receive any kind of public or private aid during the 12-month period shown in
item 8?
No (If "No," go on to item 16.)
Yes (If "Yes," give the following information.) (Include
payments for room and board, for household expenses,
for clothing, for medical expenses, etc.)
Total Amount
Date and Amount
NAME OF PERSON FOR WHOM AID
NAME AND ADDRESS
Contributed
Of
Last Contribution
WAS GIVEN
OF AGENCY
By Each
DATE

$

AMOUNT

$

$

$

$

$

16. Complete this item if you deposited or withdrew funds from a bank account during the 12-month period shown in
item 8.
Total Deposits Made
Total Withdraws Made
OWNER(S) OF ACCOUNT
During Period
During Period
$

$

$

$

$

$

17. Give the nature and amount of any other funds which were used for support (or saved) during the 12-month period
shown in item 8.

Form SSA-760-F4 (04-2014) EF (04-2014)

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18. State the nature and amount of your debts, if any, at the end of the period shown in item 8. (If none, write "None.")
DESCRIPTION

DATE INCURRED

AMOUNT
$
$
$

19. State any additional facts which you believe tend to show that you were receiving at least one-half of your support
from the worker during the period shown in item 8.

REMARKS: (This space is for more detailed answers to the above questions, if necessary. If you need more space,
attach a separate sheet.)

I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime
punishable under Federal law by fine, imprisonment or both. I affirm that all information I have given in this
document is true.

SIGNATURE OF APPLICANT
SIGNATURE ( First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)
TELEPHONE NUMBER (Area Code)

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 only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant making the request must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (Number and street, City, State and ZIP Code) ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-760-F4 (04-2014) EF (04-2014)

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Privacy Act Statement
See Revised Privacy Act Statement Attached
Sections 202(a), (c), (f), and (h) of the Social Security Act, as amended, authorize us to collect
this information. We will use this information to determine claim eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may result in the denial or reduction of benefits.
We rarely use the information for any purpose other than for determining claim entitlements.
However, we may use it for the administration and integrity of Social Security programs. We
may also disclose the 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 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, (check statue)
4. To facilitate statistical research, audit, and investigatory activities necessary to assure
the integrity and improvement 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 and administered benefit programs and for repayment of
payment's or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notice entitled, Claims Folders Systems, 60-0089. This notice, additional information
regarding our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.

See Revised PRA Statement Attached
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 30 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore,MD 21235-6401.

Form SSA-760-F4 (04-2014) EF (04-2014)

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SSA will insert the following revised PRA Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(h) and 202(k)(5)(A) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to make a determination of eligibility
for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0089, entitled Claims Folders Systems. Additional
information about this and other system of records notices and our programs is available online
at www.socialsecurity.gov or at your local Social Security office.
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
incorrect payments or delinquent debts under these programs.

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
(OMB) control number. We estimate that it will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.