Form SSA-2519 Child Relationship Statement

Form Approved
OMB No. 0960-0116

Social Security Administration

See Revised Privacy Act

CHILD RELATIONSHIP STATEMENT Statement Attached.

Privacy Act Statement - Collection and Use of Information - Section 216(h)(3) of the Social Security Act, as amended,
allows us to collect this information. We will use the information you provide to establish the child's relationship to the
applicant. 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 the claim. We rarely use the information you supply for any purpose
other than what we state above, 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 Folder System. Additional information
about this and other system of records notices and our programs are available from our Internet website 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 - 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 1-800-772-1213 (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.
PRINT WAGE EARNER'S NAME

WAGE EARNER'S SOCIAL SECURITY NUMBER

List below all children of the wager earner (hereafter referred to as the worker) for whom you are requesting benefits.
NAME OF CHILD OR CHILDREN

A child of the worker may be entitled to benefits if: (1) the worker was decreed by court to be the child's parent; or (2) the
worker was ordered by a court to contribute to the child's support because the child is his or her son or daughter; or (3) the
worked acknowledged in writing that the child is his or her son or daughter; or (4) the child is living with or receiving
contributions from his or her parents at certain times. The questions below are designed to help Social Security determine if
the child can meet these requirements. Please use item 4 on the reverse of this form for any comments you wish to make.
Yes
No
1. Was the worker ever decreed by a court to be the child's parent?
If "YES," please submit a copy of that decree or give use the name of the court and the date of the decree.
(If "YES," omit items 2, 3, and 4.)
2. Was the worker ever ordered by a court to contribute to the child's support because the
Yes
No
child was his or her son or daughter?
If "YES," please submit a copy of that decree or give us the name of the court and the date of the decree.
(If "YES," omit items 3 and 4.)
If you answer "YES" to any of the questions under Item 3, submit the document if available or complete Item 4 on
the reverse side of this form. If you are unsure of an answer explain in Item 4.
IN ALL CASES COMPLETE NAME AND ADDRESS BLOCK ON THE OTHER SIDE OF THE FORM.
3. (a) Did the worker ever file an application with or make a statement to the Veterans
Administration or welfare office or to any government agency in which he/she stated
the child was his/hers?

Yes

No

(b) Has the worker written any letters to anyone that you know of in which he/she may have
referred to the child as a son or daughter or referred to himself/herself as the child's parent?

Yes

No

(c) Did the worker ever list the child in a family tree or other family record?

Yes

No

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(d) Did the worker ever list the child as dependent on a tax return?

Yes

No

(e) Did the worker ever take out any insurance policies on the child or make the
child a beneficiary of his/her own insurance policy?

Yes

No

(f) Did the worker ever make a will listing the child beneficiary?

Yes

No

(g) Did the worker ever make an allotment for the child while he/she was in military service?

Yes

No

(h) Did the worker ever list the child on any applications for employment?

Yes

No

(i) Did the worker ever register the child in school or place of worship or sign a
Yes
No
report card as the child's parent?
(j) Did the worker ever take the child to a doctor's or dentist's office or to a hospital
Yes
No
and list himself/herself as parent?
(k) Did the worker accept responsibility for or pay the child's hospital expenses at
Yes
No
birth or did he/she give the information for the child's birth certificate?
(l) Do you know of any other written evidence of any kind which would show that
Yes
No
the child is the son or daughter of the worker? (The information need not have
been supplied by the worker.)
(m) Is there anyone to whom the worker admitted orally that he/she was the parent
Yes
No
of the child?
(n) Is the worker making regular and substantial contributions to the child's support
Yes
No
or was the worker making such contributions at that time the worker died?
4. If you answered "YES," to any of the questions in Item 3 identify the question (e.g., "3(a)") and supply detailed information
below. For example: You should provide the names and addresses of government agencies, doctors, hospitals, schools,
etc. where appropriate. The approximate date of the event and the surrounding circumstances should be indicated. The
information should be in sufficient detail to enable us to locate the document or evidence remembering the final
responsibility for supplying this evidence is yours. Where more than one child is filing for benefits identify below the child
to whom the evidence pertains.

NAME OF PERSON COMPLETING FORM

DATE

ADDRESS (NUMBER AND STREET OR P.O. BOX, OR RURAL ROUTE)

TELEPHONE NO. & AREA CODE

CITY AND STATE

ZIP CODE

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5. FOR DISTRICT OFFICE USE ONLY
A. Explain all development taken as a result of "YES" answers. Questions 3(l) and 3 (m) are designed to uncover sources
of "Other Evidence" of parentage where the child was living with or receiving contributions from the worker at the
appropriate times, or to uncover other sources of an acknowledgement in writing by the worker.

B. Outline all other pertinent relationship development made on this claim. (This suffices for the required RC.) When
considering the status of an out-of-wedlock child, you may not disallow the child until you consider applicable State
intestacy law.
State of Domicile:

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