Application for Mother's of Father's Insurance Benefits / SSA-5-BK

Form Approved
OMB No. 0960-0003

REPORTING RESPONSIBILITIES FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE
REPAID, AND IN POSSIBLE MONETARY PENALTIES
retirement
u

You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)

u

Your citizenship or immigration status changes.

u

You go outside the U.S.A. for 30 consecutive days
or longer.

u

u

Any beneficiary dies or becomes unable to handle
benefits.

Work Changes - On your application you told us
you expect total earnings for
to be
$
.

You
than $

(are)

(are not) earning wages of more
a month.

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes)

u

or disability

You begin to receive a government pension or
annuity (from the Federal government or any State
or any political subdivision thereof) or your pension
or annuity amount changes.

u

You
have
unsatisfied
for your
arrest
for
You have
an an
unsatisfied
felony orwarrant
arrest warrant
for more
than 30
acontinuous
crime or
attempted
crime
that
is
a
felony
(or,
in
days for flight to avoid prosecution or confinement, escape
jurisdictions that do not define crimes as felonies, a
from custody, or flight escape.
crime that is punishable by death or imprisonment
for a term exceeding 1 year.)

u

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

WORK AND EARNINGS
For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount. You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if
applicable) as the report of earnings required by law
and adjust benefits under the earnings test. It is your
responsibility to ensure that the information you give
concerning your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.
HOW TO REPORT

u

Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report marriage
even if you believe that an exception applies.

You can make your reports by telephone, mail, or in
person, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:

u

Custody Change or Disability 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, if disabled, the condition improves.

u
u

u

u

You
areconfined
confined
jail, penal
prison,
penalorinstitution
You are
to jail,to
prison,
institution
correctional or
correctional
facility
for
conviction
of
a
crime or you
facility for more than 30 continuous days for conviction of a crime or
are confined to a public institution by court order in
you are confined
for more
than 30 continuous days to a public
connection
with
a crime.
institution by court order in connection with a crime.

Calling us TOLL 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, visiting or writing your local Social Security
office at the phone number and address shown on
your claim receipt.

For general information about Social Security, visit our
web site at www.socialsecurity.gov.

NOTICE ABOUT DOCUMENTS
We recommend that you keep all documents you submitted to us.
We are returning the documents you submitted with this claim.
Form SSA-5-INST (07-2009) EF (07-2009)

Destroy Prior Editions

Collection and Use of Information From Your Application
Privacy Act Notice
The Social Security Administration (SSA) is authorized to collect the information on this form under sections 202, 205, and 223 of the
Social Security Act. The information you provide will be used by SSA to determine if you or a dependent is eligible to insurance
coverage and/or monthly benefits. While completion of this form is voluntary, failure to provide all or any part of the requested
information may effect our ability to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to
benefit payments.

See Revised Privacy Act Statement Attached

The information you furnish on this form may be disclosed by SSA as generally permitted under 5 U.S.C.§ 522a(b) of the Privacy Act, as
amended. This includes using the information: (1) to assist Social Security in establishing the right of an individual to Social Security
benefits; (2) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security
programs; and (3) to comply with Federal laws requiring the release of information from our records.
SSA may also use the information you give us when we match records by computer. Matching programs compare our records with
those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person
qualifies for benefits paid by the Federal government. The law allows SSA to do this even if you do not agree to it.
Explanation about reasons why information you provide us may be used or provided to other agencies are available upon request from a
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 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. 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-5-INST (07-2009) EF (07-2009)