Current SSA-5-INST

Form SSA-5-INST (07-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
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
• 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.)
• Your citizenship or immigration status changes.
• You go outside the U.S.A. for 30 consecutive days
or longer.
• Any beneficiary dies or becomes unable to
handle benefits.

• You begin to receive a retirement or disability government
pension or annuity (from the Federal government or any
State or any political subdivision thereof) or your pension
or annuity amount changes.
• You have an unsatisfied felony or arrest warrant for more
than 30 continuous days fro flight to avoid prosecution or
confinement, escape from custody, or flight escape.

(Report AT ONCE if this work pattern changes)

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.

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

HOW TO REPORT
You can make your reports by telephone, mail, or in person,
whichever you prefer.

• 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.

If you are awarded benefits, and one or more of the above
change(s) occur, you should report by:

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

• If you are deaf or hearing impaired, calling us TOLL FREE
at TTY 1-800-325-0778; or

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

(are)

(are not) earning wages of more than
a month.

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

• Calling us TOLL FREE at 1-800-772-1213;

• 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 (07-2018) UF

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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 (OMB) control number. We estimate that it will take about 15 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