Form SSA-1425 REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYME

Form Approved
OMB No. 0960-0073

SOCIAL SECURITY ADMINISTRATION

REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT
USE THIS FORM ONLY WHEN THERE IS A CHANGE TO BE REPORTED
PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
You should include the letter or letter and number A, B, B2 C, C1,
D, E, F, or H.
Your report cannot be processed without the correct claim number.

LETTER

DO YOU GET SSI BENEFITS? (Check one)
1.

CHANGE OF ADDRESS (Print new address at bottom)
If Social Security sends your payments to your financial organization,
do you want this to continue?

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2007?
If you attain full retirement age (FRA) in 2007, your exempt amount is $34,440 ($2,870 a
month )for the months before the month you attain FRA. If you attain FRA in 2008 or
later, your exempt amount is $12,960 ($1,080 a month)
a. I am working for wages of more than $1, 080 a month (under FRA
COMPLETE BOTH
BOXES
in 2007) or $2,870 a month (if year of FRA attainment) or performing
substantial services in self-employment beginning with the month of_ _ _ _ _ _ _
b. I estimate that my total earnings for this taxable year will be
3.
STOPPING WORK OR LIMITING EARNINGS:
a. The last month I worked for wages of more than $1,080 (under FRA in 2007) or
$2,870 (if year of FRA attainment) or performed substantial services in
COMPLETE
self-employment was

YES

NO

YES

NO

2.

MONTH AND YEAR

AMOUNT

$
MONTH AND YEAR

AMOUNT

BOTH BOXES

$

b. I estimate that my total earnings for this taxable year will be
4.

CHANGE IN ESTIMATE:
I estimate that my total earnings for this taxable year will be

5.

CHECK if you are self-employed, an officer of a corporation, or related to an
officer of a corporation.

6.

DEATH

7.

DATE OF DEATH:

9.

AMOUNT

$

DIVORCE

8.

DATE OF DIVORCE:

MARRIAGE (Place of Marriage) (City, County & State)

ANNULMENT
DATE OF ANNULMENT:

DATE OF MARRIAGE (MO., DAY, YR.) PRINT NEW LAST NAME

CHECK if spouse is now receiving Social Security benefits
IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S
NAME

SPOUSE'S CLAIM NUMBER

10.

GOING OUTSIDE THE U.S.
FOR 30 CONSECUTIVE
DAYS OR LONGER

DATE GOING

11.

CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR
CARE OR OTHERWISE CHANGED ADDRESS.

DATE LEFT YOUR CARE

12.

CONFINEMENT OR IMPRISONMENT
Confinement in a jail, prison, or other penal institution or correctional facility, based on a
conviction. Confinement in an institution by court order as a result of certain criminal cases.

DATE OF CONFINEMENT
(MONTH, DAY, YEAR)

13.

GOVERNMENT PENSION OR ANNUITY

MONTH AND YEAR

NAME OF COUNTRY TO WHICH GOING

DATE EXPECT TO RETURN

a. I began receiving a government pension or annuity from the Federal
government or any State or any political subdivision or my present
payments have changed beginning with the month of

MONTHLY AMOUNT

$

COMPLETE BOTH BOXES

b. The amount of government pension or annuity I receive is or has been changed to
14.

BEGINNING DATE ENDING DATE

RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT
AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR
ANNUITY, STOPPED.

MONTH/YEAR

SIGNATURE OF PERSON MAKING THIS REPORT

MONTH/YEAR

DATE SIGNED

NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE

IS THIS A NEW ADDRESS?

Yes
CITY, STATE

LETTER

ZIP CODE

Form SSA-1425 (12-2006) Destroy Prior Editions EF (12-2006)

No

NAME OF COUNTRY, IF ANY, IN
WHICH YOU LIVE

TELEPHONE NUMBER WHERE WE CAN REACH YOU
(INCLUDE AREA CODE)

HOW TO REPORT

CONFIDENTIAL INFORMATION

There are three ways to report:

The information you give on this form will be used to
determine if you are still eligible for Social Security
benefits and to make sure the amount of your benefit is
correct. Under certain limited conditions authorized by
law or regulation, Social Security may disclose this
information to another individual or government agency
in order to:

1. PHONE Social Security and explain the change.
Telephone Number (

(Area Code)

)

2. VISIT Social Security
3. MAIL this form to Social Security. Make sure you fill in:
·• NAME of person(s) the report is about

• The correct CLAIM NUMBER under which the
benefits are payable

• Whether the person(s) also receives SSI or Black
Lung benefits.
• WHAT is being reported
• DATE it happened
• Your SIGNATURE and ADDRESS
If you mail your report, please use this reporting form and send
it to the nearest Social Security office.
NOTE:

REMEMBER TO TELL US WHEN YOU MOVE,
EVEN IF YOUR MAILING ADDRESS FOR
CHECKS HAS NOT CHANGED.

WHAT TO REPORT
The law Sections 202, 203, and 205 of the Social Security Act,
as amended (42 United States Code 402, 403, and 405.)
required you to promptly report certain changes in your
circumstances which could affect your continuing eligibility to
benefits or your benefit amount. The kinds of changes you
must report to Social Security are listed on the reverse side of
this form. The booklet, "Your Social Security Rights and
Responsibilities, "tells more about reporting changes. If you
do not have this booklet or if you want help in making a
report, get in touch with any Social Security office. The people
there will be glad to help you.

FAILURE TO REPORT

• assist Social Security in establishing the right of an
individual to Social Security benefits and/or the
amount of the benefits;
• facilitate statistical research and audit activities
necessary to assure the integrity and improvement of
the programs administered by Social Security; and
• comply with Federal laws requiring the exchange of
information between Social Security and another
agency (such as the General Accounting Office and
the Veterans Administration).
We 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, and 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
us to do this even if you do not agree to it.
Explanations about these and other reasons why
information you provide us may be used or given out are
available in Social Security offices. If you want to learn
more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT
PAPERWORK REDUCTION ACT: This information
collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by Section 2 of the Paperwork
Reduction Act of 1995. You are not required to answer
these questions unless we display a valid Office of
Management and Budget control number. We estimate
that it will take you about 5 minutes to read the
instructions, gather the necessary facts, and answer the
questions.

If you do not report changes in your circumstances, 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.
If you hide or do not report a change with the intent to
fraudulently get more benefits or benefits not due you,
you may be fined, imprisoned, or both per Section 208 of
the Social Security Act.

Use this form only when there is a change to report to Social Security
Form SSA-1425 (12-2006) EF (12-2006)