Form SSA-5-BK (revised) SSA-5-BK (revised) Application for Mother's or Father's Insurance Benefits

See Revised Privacy Act Statement Attached

See Revised PRA
Statement Attached

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST
BE REPAID . AND IN POSSIBLE MONETARY PENALTIES
•

•
•

You change your mailing address for checks or
• Y.ou-violated fm ore than 30 continuous -days a coneition
residence . (To avoid delay in receipt of checks you
0f-:1ottr probatien er par-0le uAder Federal or State- law .
should ALSO file a regular change of address notice with • ,e_You~
~tJ ~(f2\~U
!'l'\IZ .ll O
.''o' \,\:j
begin to receive
a retirement
or i).'\~Ll
disability
your post office.)
You begin to recei ve a government pension or annu ity
government
pension
or annuityor(from
the Federal
(from the Federa
l government
any State
or any political
subdivisionor
thereof)
or your
pension
or annui
ty amount
Your cit izenship or immigration status changes .
government
any State
or any
political
subdivision
changes .
thereof) or your pension or annuity amount changes.
You go outside the U .S .A. for 30 consecutive days
or longer.
WORK AND EARNINGS

•

Any beneficiary dies or becomes unable to
handle benefits .

You D (are)
(are not) self-employed rendering
substantial services in your trade or business.

For those under full ret irement age , the law requires that a
report of earnings be filed wi th SSA w ith in 3 months and 15
days after the end of any ta xable yea r in which you earn morE
than the annual exempt amount. You may contact SSA to file
a report . Otherwise, SSA wi ll use the earn in gs reported by
your employer(s ) and your self-employment tax return (if
applicable) as the re port of earnings. It is your responsibility tc
ens ure that the information you give conce rning your earningi
is correct. You must furnish additional information as needed
when your benefit adjustment is not correct based on the
earnings on your record .

•

Work Changes - On you r appl ication you told us you
expect total earnings for _ _ _ _ to be $ _ _ __

(Report AT ONCE if this work pattern changes.)

HOW TO REPORT

•

Change of Marital Status - Marriage , divorce , annu lment
of marriage . You must report a change in ma rital status
even if you believe that an exception applies.

You can make your re ports by te lephone . mail , or in person ,
wh ichever you prefer.
If you are awarded benefits , and one or more of the above
change(s) occur, you shou ld report by :

•

Custody Change or Disabi lity Improves - Report if a
person for whom you are filing , or who is in your care
dies, leaves your care or custody , changes address , or 1f
disabled . the condition improves .

•

You are confined to jail , prison , pena l institution or
correctional facility for more than 30 continuous days for a
conviction of a crime or you are confined for more than 30
continuous days to a public institution by a court in
connection with a crime .
For general information about Social Security . visit our web
site at www .socialsecurity.gov .
You
warrant
than
30
Youhave
haveananunsatisfied
unsatisfied
felonyforormore
arrest
warrant
for
continuous days for y-EH:1-r-a-ue&~sr~mc or attempted
more that
thanis30
continuous
for flight
to tion
avoid
crim9
a lelon~
Gr-flightdays
to avoid
prosecu
or
confinement,
from custody
, andfrom
fligh t-escape
. -4+prosecution escape
or confinement,
escape
custody,
rnost jurisiaieliofls tnet do 1,ot-el-a~crntes.
or flight escape.
~,lies..to..a-Gj:j~t-is
pYn-isl'tebte--by dea ti 1'01
~son me At .fer-e-t,erm--e,ceeecl~gar•...i-ct1t...e,..
s""'
s .,..
Of-+tll.e..a.c!J.1 aJ seoteo~impes-ed}.-

You

D (are) D (are not) earning wages of more than

$ _ _ _ __ a month .

D

•

Form SSA-5-BK (05-2015) UF (05-2015 )

•

Page 7

Visiting the section "What You Can Do Online'' at our
web site at www.socia lsecurity.gov ;
Calling us T OLL FREE at 1-800-772-1213;
If you are deaf or hearing impaired , calling us TOLL
FREE at TTY 1-800-325-0778; or
Calling , v isiting or writing your local Social Security
office at the phone number and address shown on
you r claim receipt.

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 202, 205, 223, 226, and 806 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent us from making an accurate and timely decision on your
entitlement or a dependent’s entitlement to Social Security benefit payments.
We will use the information to determine your or a dependent’s eligibility for Social Security
benefits. We may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act). Such disclosures include, but are not limited to, release of information to:
Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance
Act and for administering provisions of the Social Security Act relating to railroad
employment; and Department of Veterans Affairs for administering 38 U.S.C. 1312, and
upon request, for determining eligibility for, or amount of, veterans benefits or verifying
other information with respect thereto pursuant to 38 U.S.C. 5106; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under the routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0059, Earnings Recording and Self-Employment Income System, 60-0089, entitled
Claims Folders Systems, 60-0090, entitled Master Beneficiary Record, and 60-0321, entitled
Medicare Database. Additional information and a full listing of all our SORNs are available on
our website at www.ssa.gov/privacy/sorn.html.
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. 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 1-800772-1213 (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.