Form SSA-781 Certificate of Responsibility for Welfare Care of a Chil

Form SSA-781 (08-2019) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0019

CERTIFICATE OF RESPONSIBILITY FOR WELFARE
AND CARE OF CHILD NOT IN APPLICANT'S CUSTODY
All items on this form requiring an answer must be answered or marked "Unknown."
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
I make this statement in support of my application for insurance benefits payable under Title II of the Social Security Act,
as amended.
1. Give the following information about all unmarried children of the above wage earner or self-employed person who are not
living with you and are: (a) under age 16, or (b) age 16 or over, with a disability that began before age 22. Include natural
children, adopted children, stepchildren, and dependent grandchildren or step-grandchildren.
NAME, ADDRESS, TELEPHONE
How long from
DATE CHILD
NUMBER AND RELATIONSHIP
today will the
REASON CHILD
FULL NAME OF CHILD
LEFT YOUR
(TO CHILD) OF PERSON
child be away LEFT YOUR HOME
HOME
WITH WHOM CHILD
from you?
IS NOW LIVING

2. (a) If you contribute to the support of any child named in item 1 above, give the following information:
FIRST NAME OF CHILD

AMOUNTS CONTRIBUTED

HOW OFTEN YOU CONTRIBUTE

$
$
$
$
(b) If you are not contributing to the support of any child named in 1 above, give name of child and state why you are not
doing so.

Form SSA-781 (08-2019) UF

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3. State how often you do any of the things shown below for any child named in item 1.
FIRST NAME OF CHILD

VISIT

SEND
CLOTHING

MAKE OTHER
GIFTS

WRITE LETTERS

4. Do you give the person or persons with whom the child or children have been placed
instructions for the care of such child or children?

Yes

OTHER (DESCRIBE)

No

If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are carried out.

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
SIGNATURE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, day, year)
Telephone Number(s) At Which You May Be
Contacted During The Day (include area code)

MAILING ADDRESS (Number and street, P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

Enter Name of County (if any) In Which You Now Live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
2. SIGNATURE OF WITNESS
1. SIGNATURE OF WITNESS
Address (Number and street, City, State and ZIP Code)

Address (Number and street, City, State and ZIP Code)

Form SSA-781 (08-2019) UF

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PRIVACY ACT STATEMENT:
See Revised Privacy Act &
Collection and Use of Personal Information PRA Statements attached
Section 202 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 claim for Social Security Administration (SSA) provided benefits.
We will use the information to determine your eligibility for benefits. We may also share your information for the following
purposes, called routine uses:
•

Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose of assisting the SSA
in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations
in which SSA may enter a contractual or similar agreement with a third party to assist in accomplishing an agency function
relating to this system of records; and

•

To a congressional office in response to an inquiry from that office made at the request of the subject of a record.

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
Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information, and a full listing of
all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 10 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.