Form SSA-3989 Statement for Determining Continuing Eligility for Suppl

Form Approved
OMB No. 0960-0643

3989 1

Social Security Administration

STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR
SUPPLEMENTAL SECURITY INCOME PAYMENTS--CHILD
DRDP:
RUN:
JD:
STC:
WI:
TPI:
FLA:
PROFILE:
DOC:
CFL:
HUN:
FUN:
TMR:
TEL:
LANGPREF:

NAME AND ADDRESS

RETURN THIS FORM WITHIN 30 DAYS FROM RECEIPT
PRINT ANSWERS LIKE THIS ►

Yes

0 1 2 3 4 5 6 7 8 9
Month

Day

Year

0 4

0 1

2 0 0 6

PRINT DATES LIKE THIS ►

OR LIKE THIS ►

No
X

If the mailing address shown above is not correct, provide the correct mailing address
(Number, Street, City, State, and Zip Code):

None-N/A

Street:____________________________________________ Apartment No.__________
________________________________________________________________________
________________________________________________________________________
City:____________________________ State:___________ Zip Code:
YOUR SOCIAL SECURITY NUMBER (SSN):

{Pre-Printed}

BECAUSE YOU ARE THE REPRESENTATIVE PAYEE, YOU MUST ANSWER THE FOLLOWING QUESTIONS AS IF
{name of child} WERE COMPLETING THE FORM.

1.

Since {Pre-Printed}, has the child’s marital status changed?

Yes

If the answer to the question is “no,” go to Question 2.
If the answer to the question is “yes,” please check the marital status that now applies to the child.
Married living with Spouse

Married NOT living with Spouse

Divorced

Widowed

Date marital status changed (Month/Year)

Single

No

3989 2
2.
Since {Pre-Printed}, has the marital status of the parents living with the child changed?

Yes

No

If the answer to the question is “no,” go to Question 3.
If the answer to the question is “yes,” please check the marital status that now applies to the parent(s).
Married living with Spouse

Married NOT living with Spouse

Divorced

Widowed

Single

Date marital status changed (Month/Year)
3.

Yes

Does the child live with either of his/her parents?

No

If “no”, go to Question 4.
Since {Pre-Printed}, has anyone moved into or out of the child’s household?
(include births and deaths)
If “yes”, please give the following information about them (including children).
If “no”, go to Question 4.
a. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Sister

Date Moved In

Brother

None-N/A
Other Relative

Date Moved Out

b. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Sister

Date Moved In

Brother

None-N/A
Other Relative

Date Moved In

Other _________________

Date Moved Out

c. Name:____________________________________________
Relationship:

Other _________________

Spouse

Mother

Father

Sister

Brother

None-N/A
Other Relative

Other _________________

Date Moved Out

4.

Yes

No

Since {Pre-Printed}, has the child or the child’s representative payee moved to a new address?
If the answer to the question is “no,” go to Question 5.
If the answer to the question is “yes,” go to next page.
Question continues on the next page

3989 3
Child’s new address:
ADDRESS (Number, Street, City, State, and Zip Code):

None-N/A

Street:____________________________________________ Apartment No.__________
________________________________________________________________________
________________________________________________________________________
City:____________________________ State:___________ Zip Code:
Date the Person Moved (Month/Year)
Representative Payee’s new address:
ADDRESS (Number, Street, City, State, and Zip Code):

None-N/A

Street:____________________________________________ Apartment No.__________
________________________________________________________________________
________________________________________________________________________
City:____________________________ State:___________ Zip Code:
Date the Person Moved (Month/Year)
5.

List all the people who live in the same household with the child.
a. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Sister

Brother

b. Name:____________________________________________
Spouse

Mother

Father

Sister

Brother

c. Name:____________________________________________
Spouse

Mother

Father

Sister

Brother

d. Name:____________________________________________

Date of Birth

Other Relative

Other _________________

None-N/A
Other Relative

Other _________________

Social Security Number

Date of Birth

Relationship:

None-N/A

Social Security Number

Date of Birth

Relationship:

Other _________________

Social Security Number

Date of Birth

Relationship:

Other Relative

Spouse

Mother

Father

Sister

Brother

None-N/A
Other Relative

Other _________________

Social Security Number

Question continues on the next page

3989 4
e. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Sister

None-N/A

Brother

Other Relative

Other _________________

Social Security Number

Date of Birth

If you need more space use the REMARKS Section on page 10.
6.

Do the child’s parents own or rent the place where the child lives?

Yes

No

Yes

No

If the answer to the question is “no”, go to Question 7.
If the answer is “yes”, check the answer that applies:
7.

Own

Rent

Since {Pre-Printed}, has the child been in a hospital, nursing home, jail or prison, or other
institution for a full calendar month or longer? (A “full calendar month” means, for example,
from December 1 through December 31.)
If the answer to the question is “no,” go to Question 8.
If the answer to the question is “yes”, please give:
Date Entered
(Month/Day/Year)

Date Discharged
(Month/Day/Year)

a.
Hospital

a.
Nursing Home

Name and Address of Institution:

Jail

Other Institution __________________________

None-N/A

___________________________________________________________

____________________________________________________________________________________
b.
Hospital

b.
Nursing Home

Name and Address of Institution:

Jail

Other Institution __________________________

None-N/A

___________________________________________________________

____________________________________________________________________________________
8.

Since {Pre-Printed}, has the child been outside the United States (the 50 States, District of
Columbia, and the Northern Mariana Islands) for more than 30 days in a row?

Yes

No

If the answer to the question is “no,” go to Question 9.
If the answer to the question is “yes,” please give:
Date(s) Left
(Month/Day/Year)

Date(s) Returned
(Month/Day/Year)

Where Did the Child Go?

________________________ N/A
a.

a.

b.

b.

________________________
________________________ N/A
________________________

3989 5
9.

Yes No

Since {Pre-Printed}, has the child, father or mother living with the child worked?

Is the child, father or mother living with the child currently working?

Do you expect the child, father or mother living with the child to work in the next 14
months?
If the answer to all 3 of the questions is “no,” go to question 10.
If the answer to any of the 3 questions is “yes,” please give:

Mother

Father

Child

Example: If you have $600, it would be printed
like this. SHOW DOLLARS ONLY
Name of Employer/
Address

$

,

6 0 0

Gross Wages
(Before Any Deductions)

____________________

Amount: $
____________________
Paid: Weekly

,

Dates of Employment

From:

.
BiWeekly

.

Monthly

To:
____________________

Amount:

____________________
Paid:
____________________

Paid:

,

Weekly

Amount:

____________________

$

$

BiWeekly

,

Weekly

From:

.
Monthly

From:

.
BiWeekly

To:

Monthly

To:

Is the child a student?
10.

Since {Pre-Printed}, has the child or have the parent(s) living with the child been selfemployed or expect to be self-employed in the current taxable year?

Yes

No

Yes

No

If the answer to the question is “no,” go to Question 11.
If the answer to the question is “yes,” please give:
Child

N/A

Father

N/A

Mother

N/A

Type of Business

______________ ______________ ______________
______________ ______________ ______________

Total Gross Income for Last Year

$

,

.

$

,

.

$

,

Question continues on the next page

.

3989 6
N/A

Child
Net Income for Last Year

$

Estimated Gross Income for this
Year

$

Estimated Net Income for this Year

$

11.

,
,
,

.
.
.

Father

$
$
$

,
,
,

N/A

.
.
.

Mother

$
$
$

Since {Pre-Printed}, has the child or have the parent(s) living with the child received, or expect
to receive in the next 14 months, any of the income listed below:

N/A

,
,
,

.
.
.
Yes No

A. Private pensions or annuities (do not include Social Security, SSI, or food stamps)?
B. Unemployment or worker’s compensation?
C. Welfare or State or local assistance based on need?
D. Veterans Administration benefits (based on need, not based on need, education)?
E. Railroad Board, Black Lung, Military or Civil Service pensions?
F. Rental/lease income?
G. Alimony or child support?
H. Dividends or royalties?
I. Interest earned on money in bank accounts (including interest in checking account)?
J. Money from a trust fund?
K. Money from any other person or organization?
L. Any other income not included above?
If the answer to all 12 of the questions is “no,” go to Question 12.
If the answer to any of the 12 questions is “yes,” tell us about that item. Please give:
Amount /How Often
(use whole dollars)

Mother

Father

(choose
from letters
above)

Child

Type of Received by
Income

$
Weekly

Dates Received or Expected

Source
(Name/Address of Person, Bank,
Company or Organization)

_______________________ N/A

,

.
BiWeekly

From:

Monthly
To:

_______________________
_______________________

3989 7
Amount /
How Often

Mother

Father

(choose
from letters
above)

Child

Type of Received by
Income

$

.
BiWeekly

From:

Monthly
To:

$

,

Weekly

.
BiWeekly

From:

,

Weekly

.
BiWeekly

From:

Weekly

_______________________
_______________________ N/A

_______________________
_______________________ N/A
_______________________

Monthly
To:

$

_______________________

_______________________

Monthly
To:

$

Source
(Name/Address of Person, Bank,
Company or Organization)

_______________________ N/A

,

Weekly

Dates Received or Expected

_______________________
_______________________ N/A

,

.
BiWeekly

From:

Monthly
To:

_______________________
_______________________

12.

Is the child’s SSI check sent directly to a bank or other financial institution? (This is known
as “Direct Deposit”)

13.

Does the child or do the parents living with the child own any of the following items?
Answer “Yes”, if the child’s name or the parent(s) name, appears alone or with any other
person as the owner or part owner for any of these items:

Yes

No

Yes No

A. Cash (with you, at home, or in a safe deposit box)?
B. Checking or savings accounts?
C. Money market accounts?
D. Credit union accounts?
E. Christmas club accounts?
F. Savings certificates/certificates of deposit?
G. Promissory notes or IOU’s?
Question continues on the next page

3989 8

Yes No
H. Stocks, bonds or U.S. Savings Bonds?
I. Trusts?
If the answer to all 9 of the questions is “no,” go to Question 14.
If the answer to any of the 9 questions is “yes,” please give:
Name of Owner or
Each Co-Owner
Item
Name and Address of Bank, Company or Organization

Mother

Father

Total Value of Each
Child

(choose
from
letters
above)

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

14.

Does the child or do the parent(s) living with the child own or partially own, land, buildings
or other houses where the child does not live? (Include property outside the U.S., inherited
property, and life estates. Do not include the home you live in.)

Yes

No

If the answer to the question is “no,” go to Question 15.
If the answer to the question is “yes,” please give:

Estimated Current
Market Value

Mother

Father

Child

Owner or
Co-Owner

$
$

,
,

Tax Assessed Value, if
known

.
.

$
$

,
,

Amount of Mortgage
Payment, if any

.
.

$
$

,
,

.$
.$

Amount Owed on this
Property

,
,

Question continues on the next page

.
.

3989 9
Description (Include type and size of structures, acreage or lot size, and location of property)

N/A

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Use (Describe how the property is used. If not in use, give date of last use and next planned use.)

N/A

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
15.

Since {Pre-Printed}, has the child had any change in health insurance coverage or other
insurance that pays for medical bills?

Yes

No

(Do not include Medicare, but do include insurance such as accident, automobile, or casualty
if it covers medical bills for any reason.)
If the answer to the question is “no,” go to Question 16.
If the answer to the question is “yes,” please explain:

None- N/A

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
16.
17.

Yes
Does the child have a parent who is age 62 or older, disabled, or deceased?
a. Which language do you prefer to use when speaking to us?
English

Spanish

Other (write in name of language): ___________________________

b. Which language do you prefer that we use to write to you?
English

Spanish

Other (write in name of language): ___________________________

No

3989 10
WE ARE REQUIRED BY LAW TO ASK THE FOLLOWING QUESTIONS OF ALL SSI RECIPIENTS

18.

Yes

a. Does the child have any unsatisfied felony warrants for
his/her arrest?

No

Name of State/Country

b. In which state or country was the warrant issued?
c. Was the warrant satisfied?

Yes

No

Yes

No

d. Date warrant satisfied
19.

a. Does the child have any unsatisfied Federal or State warrants
for violating the conditions of probation or parole?

Name of State/Country

b. In which state or country was the warrant issued?
Yes

c. Was the warrant satisfied?

No

d. Date warrant satisfied
20.

a. Since {Pre-Printed}, has the child or the parent(s) living with the
child sold, transferred title, disposed of or given away any property
including property in foreign countries?

Child

Yes

No

Father

Yes

No

Mother

Yes

No

b. Since {Pre-Printed}, has the child or the parent(s) living with the
child disposed of or given away any money?
If money was given away, please give amount: $

,

.

REMARKS: ______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

3989 11
YOUR AUTHORIZATION
I give my permission for the Social Security Administration to check the information I have given on this form, and to ask my
employer(s) for information about my wages. I understand that the Social Security Administration will compare its records with records
from other State and Federal agencies to make sure I am paid the correct amount of benefits. 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 or misleading statement about a material fact in this information,
or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURES (Write in ink)
Representative Payee’s Signature (First name, middle initial, last name)

SIGN
HERE ____________________________________________

DATE:

Area Code & Telephone Number (Where you can be reached)

(

)

None
WITNESSES (Write in Ink)

If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign
below and give their full names and addresses.
1. Signature of Witness

Address (Number, Street, City, State and Zip Code)

2. Signature of Witness

Address (Number, Street, City, State and Zip Code)

REPRESENTATIVE PAYEE (Print in ink)
If you are the Representative Payee and are filing this statement on behalf of another person give:
Your Full Name (First name, middle initial, last name)

Your Title or Relationship to the Recipient

Address (Number, Street, City, State, and Zip Code)

Your Social Security Number

Area Code & Telephone Number (Where you can be reached)

(

)

None
FOR SSA USE ONLY

WBDOC

WBDOC1

WBDOC2

WBDOC3

FO UND

FO1 DEC

FO2

FO3