Form SSA-1383-FC Report to Social Security Administration by Student Outs

Form SSA-1383-FC (01-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0088
Our address is:

REPORT TO SOCIAL SECURITY ADMINISTRATION
BY STUDENT OUTSIDE THE UNITED STATES
(Use this form ONLY when there is a change to be reported
for a United States Social Security beneficiary)

Social Security Administration
P.O. Box 17769
Baltimore, MD 21235-7769 U.S.A

SOCIAL SECURITY CLAIM NUMBER ON WHICH
BENEFITS ARE PAID. It is a nine digit number
(000-00-0000) followed by a letter or a number,
such as C, C1, HC, HC1. Your report cannot be
processed without the correct claim number

PRINT NAME OF STUDENT ABOUT WHOM REPORT IS MADE

If you need help in completing this form or additional information about your benefits, you may contact your Federal Benefits
Units. For a list of Federal Benefits Units, visit www.socialsecurity.gov/foreign/foreign.htm.
Please MAIL THIS REPORT DIRECTLY TO:

Social Security Administration
P.O. Box 17769
Baltimore, Maryland 21235-7769 U.S.A.

Be sure to affix proper postage on the envelope.
CHECK OR FILL IN ONLY THE INFORMATION BEING REPORTED
1.

CHANGE OF ADDRESS (Print new address after signature below)
Check is change is for:

More than 6 months

6 months or less

2.

EMPLOYMENT (As employee or as self-employed person)

DATE EMPLOYMENT BEGAN

3.

MARRIAGE

DATE OF MARRIAGE

4.

NO LONGER ATTENDING ANY SCHOOL. (Do NOT report this item merely because school MM/DD/YYYY
year ended if you intend to resume full-time attendance after a vacation period of not more
than 4 full calendar months.) The last day that I attended school on full-time basis was

5.

REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
The last day that I attended school on a full-time basis was

6a.

b.

c.

MM/DD/YYYY

CHANGED SCHOOLS
MM/DD/YYYY
I have arranged to change schools effective
I am (will be) attending
full-time
part-time
NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records, such as type of
school, branch or campus and division)

TYPE OF SCHOOL

Elementary or Secondary School

University

Other (explain)
d.

STUDENT IDENTIFICATION NUMBER

e.

DATE SCHOOL YEAR WILL END (MONTH, YEAR)

7a.

STUDENT SOCIAL SECURITY NUMBER

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on (MM/DD/YYYY)

b.

NAME AND ADDRESS OF EMPLOYER

Form SSA-1383-FC (01-2018)

Page 2 of 2

8.

INCARCERATION FOR CONVICTION OF A FELONY
Student is confined in a jail, prison, or other institution or correctional facility,
based on a conviction for a felony committed after October 19, 1980.

DATE OF INCARCERATION
(MM/DD/YYYY)

9.

WARRANT ISSUED FOR STUDENT'S ARREST
Do you have an unsatisfied warrant for your arrest for a crime or attempted
crime of flight to avoid prosecution or confinement or escape from custody?

DATE OF ARREST WARRANT
(MM/DD/YYYY)

SIGNATURE OF PERSON MAKING THIS REPORT

DATE SIGNED

MAILING ADDRESS (NUMBER AND STREET, APT. NO.)
CITY OR TOWNSHIP

POSTAL CODE

COUNTRY

Notice: This report is authorized in order to confirm continuing eligibility to Social Security benefits as provided by law
(section 202 (d) of the U.S. Social Security Act, as amended (42 United States code 402(d))).
WHAT TO REPORT
The kinds of events that you must report to Social Security are listed below. Check any of the events that apply to you and fill in
any other information requested about the event.
FAILURE TO REPORT
If you do not report events as shown on this form, you may not be paid some or all of the benefits due you, or you may be
overpaid, in which case, you will have to pay back any benefits you received that were not due you.
Also, if you conceal or fail to disclose a report event with an intent to fraudulently obtain benefits either in a greater amount than is
due or when no payment is authorized, you may be FINED, IMPRISONED, or both, as provided in section 208 of the Social
Security Act
OTHER USES WHICH MAY BE MADE OF THE INFORMATION ON THIS REPORT
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d), 203(h), and 205(a) 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 an accurate and timely decision on
any claim filed.
We will use the information to determine your entitlement and benefits. We may also share your information for the following
purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representative
payees to the extent necessary to pursue Social Security claims and to representative payees when the information
pertains to individuals for whom they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they serve as payees; and
2. To the Department of State and its agents for administering the Act in foreign countries through facilities and services of
that agency.
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 Notice (SORN) 60-0089 entitled Claims Folders
System. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
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 6 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.