Form SSA-1372-BK-FC Student's Statement Regarding School Attendance

Form Approved
OMB No. 0960-0105

Social Security Administration

ADVANCE NOTICE OF TERMINATION OF CHILD'S BENEFITS
NAME AND ADDRESS

SOCIAL SECURITY CLAIM NUMBER

NAME OF CHILD BENEFICIARY TO WHOM THIS
NOTICE APPLIES
DATE CHILD BECOMES AGE 18

YOUR BENEFITS WILL AUTOMATICALLY STOP AT AGE 18 UNLESS:
●

You are a full-time student at an elementary or secondary - level school (as defined
by the jurisdiction in which the school is located), or

●

You qualify for childhood disability benefits.

Your benefits will end with the payment for the month before the month in which you become age 18. You become age
18 on the day before your 18th birthday. This is important when your birthday is on the first day of the month. For
example, if your 18th birthday is June 1, you become age 18 on May 31. If you are neither a full-time student nor
disabled in May, benefits would not be payable for May. The last benefit payment to which you would be entitled would
be the one received in May, which represents your payment for April.

FOR YOU TO RECEIVE STUDENT BENEFITS AFTER AGE 18, YOU MUST:
1. Complete the form, STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE OUTSIDE THE UNITED
STATES (pages 2 and 3).
2. Take the form to the school for a school official to certify on page 4 the information you provide on pages 2
and 3.
3. Leave the form, NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE (pages 5 and 6), with the
school official.
4. Take or mail the completed pages 2, 3, and 4 of this form to one of the following offices,
● If you live in Canada, Samoa or the British Virgin Islands, the nearest U.S. Social Security Office;
● If you live in the Philippines, the SSA Division of the U.S. Veterans Affairs Regional Office, 1131
Roxas Blvd, 0930 Manila;
● If you live in any other country, the Social Security Administration, Office of International Operations,
P.O. Box 17775, Baltimore, MD 21235-7775 or call the nearest U.S. Embassy or consulate to
determine which U.S. Foreign Service post handles Social Security matters.
TO RECEIVE CHILDHOOD DISABILITY BENEFITS, YOU MUST CONTACT ONE OF THE OFFICES SHOWN ABOVE
AND HAVE THE FOLLOWING INFORMATION:
1. A history of the disabling condition, including names and addresses of medical record sources (such as
doctors and hospitals) and schools attended. If you have worked you must also furnish your work history.
2. Your U.S. Social Security Number.

Please keep the attached sheet, INFORMATION ABOUT BENEFITS PAST AGE 18 (page 7), for your records. It
contains important information about eligibility for student benefits and reporting responsibilities.

Form SSA-1372-BK-FC (02-2016) UF (02-2016)
Destroy prior editions

Page 1

Form Approved
OMB No. 0960-0105

Social Security Administration

STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE
OUTSIDE THE UNITED STATES
NAME AND ADDRESS
The information requested on this form is sought pursuant
to the authority granted by law (42 U.S.C. 402 and 405).
While you are not required to respond, your cooperation is
needed to confirm your past and/or continuing entitlement to
student benefits.
SOCIAL SECURITY CLAIM NUMBER

(To change or correct the address, line through the old
address and insert the new address.)

1. Current School Year
(a). Are you now in full-time attendance?

Yes

No

(Note: If you are completing this form during a summer break period and you were in full-time attendance prior to
the break and will continue school in the fall, you should answer YES to question 1(a). You should show the
beginning date of the fall semester/term for question 1(b). See question 2 for past school attendance information.)
(b). Print the following information about the school you attend.

School Year Began School Year Will End
(Month, Day, Year) (Month, Day, Year)

Name
Street Address
City and State or Province
(c).Show the type of school:
High School (including "gymnasium,"
"lycee," "secundaria," or other secondary
level school).

Preparatoria
Other (Specify)

(d). Show the number of hours you are scheduled to attend (e). Show the grade in which you are enrolled.
each week.

(f). Show your EXPECTED graduation date from SECONDARY school, (e.g. high school).

Month, Year

(g). What months between now and your expected graduation will you not be in full-time attendance for the full month?
(For example months of summer vacation).

2.

Last School Year
(a). Print the name and address of the school you attended in the last school year. (If it is the same as the school
shown in question 1, show "Same" and go to (b).)

3.

(b). Date the school year began (Month, Day, Year).

Date the school year ended (Month, Day, Year).

(c). Show the number of hours you were scheduled to
attend each week.

(d). Show the grade in which you were enrolled.

Next School Year
(a). Do you intend to be in full-time attendance at a school in the next school year?
Yes

No

(If "No" or "Undecided" go to question 4. If "Yes", go to (b) .)
Form SSA-1372-BK-FC (02-2016) UF (02-2016)
Page 2

Undecided

(b). Print the name and address of the school you will attend. (If it is the same as the school shown in question 1, show
"Same" and go to (c).)

(c). Date the school year will begin (Month, Day, Year).

Date the school year will end (Month, Day, Year).

(d). Show the number of hours you will be scheduled to
attend each week.

(e). Show the grade in which you were enrolled.

4. Are you disabled?

Yes

No

5. Are you married?

Yes

No

Yes

No

If "Yes," show the date you were married.
6. (a). Have you worked in employment or self-employment outside the United
States during any of the past 13 months, including the present month?
(See the information on page 7.)

(b). If "Yes," give the following information about your apprenticeship, employment or self- employment outside the
United States.
Name and Address of Employer
(If self-employed, show "self" and address at which the trade or business was conducted.)

Type of Business
Date Employment (or self- employment) Began.
Date Employment (or self-employment) Ended. (If not ended, leave blank.)
(c). Will you work in employment or self-employment in the next school year?

Yes

No

7. If you are, or will be, paid by your employer to attend school, give your employer's name and address. (If it is the same
as in question 6, write "same as above.")

8. Do you have an unsatisfied warrant, over 30 days old, issued for your arrest
because you were charged with a crime that carries a penalty of death or
confinement of over one year, or because you violated a condition of Federal
or State probation or parole?

Yes

No

I agree to promptly notify the Social Security Administration if I marry, go to work, or if there is any change in
my school attendance. I agree to return any benefit payment to which I am not entitled. I know that anyone
who makes or causes to make a false statement or representation of material fact 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 of the information that I have given in this document is true. I also
certify that I have read the detached information sheet. I authorize my school to disclose to the Social
Security Administration any information concerning my status as a student as it pertains to past, current or
future Social Security student benefits.

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

Student's Own U.S. Social Security Number
Form SSA-1372-BK-FC (02-2016) UF (02-2016)

Mailing Address

Telephone No.
Page 3

Date

Form Approved
OMB No. 0960-0105

Social Security Administration

CERTIFICATION BY SCHOOL OFFICIAL
NAME OF STUDENT

SOCIAL SECURITY NUMBER

Please review the information on pages 2 and 3, answer the questions below, annotate the student's expected
graduation date on page 5 and sign the form in the space provided. You should give the originals of pages 2, 3,
and 4 to the student to return to the U.S. Social Security Administration and keep copies in the school's files as
a record of the student's attendance that you certified. Please retain page 5 for reporting if the student's full-time
attendance ends, or the student graduates before the date shown on page 2.
1. All information entered in items 1, 2 and 3 on pages 2 and 3 is correct
according to the school's records.

Yes

No

2. Is the school's course of study of at least 13 weeks duration?

Yes

No

4. I received pages 5 and 6 of this form for reporting changes in the
student's attendance.

Yes

No

5. I annotated page 5 of this form with the student's expected graduation
date as reported on page 2 of this form.

Yes

No

3. Please indicate which of the following applies to the school's operating basis?
Yearly
Quarterly/Semester-No Reenrollment Required
Quarterly/Semester-Reenrollment Required

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 U.S. Social Security Act commits a crime
punishable under Federal law and/or State law. I affirm that all information I have given in this document is true.
SCHOOL OFFICIAL SIGNS

Title

Printed Name

Date

Form SSA-1372-BK-FC (02-2016) UF (02-2016)

Phone Number

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SCHOOL SHOULD RETAIN THIS FORM
SOCIAL SECURITY ADMINISTRATION
Office of International Operations
P.O. Box 17769
Baltimore, MD 21235 USA

Form Approved
OMB No. 0960-0105

NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE
NAME OF SOCIAL SECURITY BENEFICIARY

DATE OF BIRTH SOCIAL SECURITY CLAIM NUMBER

Individual identified above ceased to be a full time student at this school on, (Month, Day, Year).
REASON:
1. Withdrawal, suspension or expulsion.
2. Changed to PART-TIME status.
3. Failed to continue in full-time attendance at start of new term (or new school year).
4. Other (Explain).

Name and address of school

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.
Signature (or facsimile) of school official

Printed Name

Title

Date

IMPORTANT INFORMATION ABOUT THIS FORM
This form contains the name, date of birth and U.S. Social Security claim number of a child beneficiary who tells us that he/
she is (or will be when school resumes) a full-time student at your school. One of the conditions a child between 18 and 19
must meet to receive Social Security Benefits is that he/she be a full-time student.
Full-Time Attendance
For Social Security purposes, a student is one who is attending an elementary or secondary-level school, and is enrolled in
a day or evening non-correspondence course of at least 13 weeks in duration. The attendance must be at grade/year 12 or
lower. In addition, the student must be scheduled to attend at the rate of at least 20 hours weekly, and be carrying a subject
load which is considered full-time for day students under the school's standards and practices. If there is any question as to
whether the student's attendance is full or part-time, please apply your school's usual criteria.
What to Report
Please hold this form until the student is no longer a full-time student at your school (whether this is during the current
school year, at the start of the next school year, or any time after that). Then, enter the date he/she stopped being a fulltime student, check the appropriate box above and return the completed form to the Social Security office shown above,
the nearest U.S. Social Security office or the nearest U.S. Embassy or consulate. In the Philippines, return it to the SSA
Division, U.S. Veterans Affairs Regional Office, 1131 Roxas Blvd., 0930 Manila.
You should not return the form to report that attendance stopped for a scheduled break (e.g., summer break) unless you do
not expect the student to return after the break. You should report if the student stops attending school full-time, or
graduates, earlier than the date shown above.
The people in the above offices will be glad to help you with any questions concerning this form or any other questions you
have about Social Security.
Thank you for your cooperation.
Form SSA-1372-BK-FC (02-2016) UF (02-2016)

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Privacy Act Statement
Collection and Use of Personal Information

Sections 202(d) and 205(a) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to verify full-time attendance in school and to
determine whether children of an insured worker are eligible for student 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 benefit 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 complete 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 Folder System. Addition information
about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs 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 - 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 3 minutes to read the instructions, gather the 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.

Form SSA-1372-BK-FC (02-2016) UF (02-2016)

Page 6

STUDENT SHOULD KEEP THIS INFORMATION FOR FUTURE REFERENCE

INFORMATION ABOUT BENEFITS PAST AGE 18
If you qualify for Social Security benefits because you are a full-time student, you can start receiving benefits as
early as age 18 and usually through the month you graduate from the 12th grade, or the month before you
become age 19, whichever is earlier. Your benefits will be paid in your own name beginning at age 18, either by
direct deposit or by mail. Generally, we consider you to be a full-time student if you are in full-time attendance at
a school that provides education at the secondary (grade 12) level or below. Full-time attendance means you are
scheduled to attend classes at the rate of 20 hours each week, or at the rate determined by your school to be
full-time (if higher).

INFORMATION ABOUT BENEFITS PAST AGE 19
Your benefits may continue past age 19 if you are in actual full-time attendance at a school that provides
elementary or secondary education in the month you become age 19. If the school operates on a yearly basis,
then payment may be continued after age 19 up through the earlier of (1) the month you complete the course in
which you are enrolled full-time or (2) the second month after the month you become age 19. If the school
requires re-enrollment on other than a yearly basis, benefits may continue through the month ending the term
that is in progress when you become age 19. Note that payments beyond age 19 cannot be made if you become
age 19 in a month of nonattendance (for example, you become age 19 in a month when you are on summer
vacation).

IMPORTANT RESPONSIBILITIES
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:

•
•
•
•
•
•

YOU MARRY
YOU STOP ATTENDING SCHOOL
YOU REDUCE YOUR SCHOOL ATTENDANCE BELOW FULL-TIME
YOU CHANGE SCHOOLS
YOUR EMPLOYER PAYS YOU TO ATTEND SCHOOL (either at his request or as a
requirement of employment)
AN UNSATISFIED WARRANT, OVER 30 DAYS OLD, WAS ISSUED FOR YOUR ARREST
BECAUSE YOU WERE CHARGED WITH A CRIME THAT CARRIES A PENALTY OR DEATH OR
CONFINEMENT OVER ONE YEAR. OR, BECAUSE YOU VIOLATED A CONDITION OF
FEDERAL OR STATE PROBATION OR PAROLE.

Your benefits may end if any of the above occur. You must report each of these events even if you
believe your benefit should not end. We will tell you about how your benefits may be affected.
YOU MUST ALSO NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:

•
•

YOU MOVE OR CHANGE YOUR MAILING ADDRESS
YOU WORK IN EMPLOYMENT OR SELF-EMPLOYMENT

When you are awarded Social Security benefits as a student, you will receive a booklet that further covers your
responsibilities. It is important for you to read that booklet.

HOW WORK OUTSIDE THE UNITED STATES AFFECTS YOUR BENEFITS
If your earnings are not subject to U.S. Social Security taxes, a 45-hour test applies. Under this test, if you are
employed (or self-employed) on more than 45 hours in a month, you are not eligible to receive a benefit for that
month. How much you earn and how many days you work in a month does not matter. A person is employed if
he/she performs services for someone else and receives cash payment or other compensation for these
services. This includes part-time work, and work as an apprentice.
Failure to report employment in the United States or outside the United States can result in the loss of
additional benefits.
Form SSA-1372-BK-FC (02-2016) UF (02-2016)

Page 7

Privacy Act Statement
Collection and Use of Personal Information

Sections 202(d) and 205(a) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to verify full-time attendance in school and to
determine whether children of an insured worker are eligible for student 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 benefit 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 complete 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 Folder System. Addition information
about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs 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 - 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 8 minutes to read the instructions, gather the 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.

Form SSA-1372-BK-FC (02-2016) UF (02-2016)

Page 8