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

Form SSA-1383-FC (XX-XXXX)
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Social Security Administration

Page 1 of 2
OMB No. 0960-0088

REPORT TO SOCIAL SECURITY ADMINISTRATION
BY STUDENT OUTSIDE THE UNITED STATES

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

(Use this form ONLY to report a change for a United States Social
Security beneficiary)
PRINT NAME OF STUDENT ABOUT WHOM REPORT IS MADE

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. We cannot process your
report without the correct claim number.

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 ONLY THE EVENT YOU ARE REPORTING AND FILL IN THE INFORMATION REQUESTED
1.

CHANGE OF ADDRESS (Print new address on page 2 of this form)
Check if change is for:

More than 6 months

6 months or less

2.

EMPLOYMENT (As employee or as self-employed person)

DATE EMPLOYMENT BEGAN
MM/DD/YYYY

3.

MARRIAGE

DATE OF MARRIAGE
MM/DD/YYYY

4.

NO LONGER ATTENDING ANY SCHOOL (Do NOT report this item merely because school 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.

MM/YYYY
REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
The last day that I attended school on a full-time basis was
MM/YYYY
CHANGED SCHOOLS
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)

6a.

b.

c.

TYPE OF SCHOOL
ELEMENTARY or SECONDARY SCHOOL

UNIVERSITY

MM/YYYY

OTHER (explain)

d.

STUDENT IDENTIFICATION NUMBER

e.

DATE SCHOOL YEAR WILL END

MM/YYYY

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on

MM/YYYY

7a.
b.

NAME AND ADDRESS OF EMPLOYER

STUDENT'S SOCIAL SECURITY NUMBER

Form SSA-1383-FC (XX-XXXX)
8.
INCARCERATION FOR CONVICTION OF A CRIME
Student is confined in a jail, prison, or other correctional institution, based
on a conviction of a crime.

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DATE OF INCARCERATION
(MM/YYYY)

9.

DATE OF ARREST WARRANT
(MM/YYYY)

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

NAME OF PERSON MAKING THIS REPORT
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 in items 1 through 9 on this form. 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:
• To the Department of State, for administration of the Social Security Act in foreign countries through services and facilities of
that agency; and
• To claimants, prospective claimants (other than the data subject), and their authorized representatives or representative
payees, to the extent necessary to pursue Social Security claims; to representative payees, when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting us in administering representative
payment responsibilities under the Social Security Act; and to representative payees, for the purpose of assisting them in
performing their duties as payees, including receiving and accounting for benefits for individuals for whom they serve as
payees.
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, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422. Additional information, and a full listing
of all 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 (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.