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pdfForm Approved
OMB No. 0960-0643
Social Security Administration
STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR SUPPLEMENTAL
SECURITY INCOME PAYMENTS — CHILD
RETURN THIS FORM WITHIN 30 DAYS FROM RECEIPT
PRINT ANSWERS LIKE THIS
PRINT DATES LIKE THIS
0
1
2
3 4
Day
Month
0 6 / 0
5
1 / 2
6
7 8 9
Year OR LIKE THIS
0 0 6
Yes
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):
BECAUSE YOU ARE THE REPRESENTATIVE PAYEE, YOU MUST ANSWER THE FOLLOWING
QUESTIONS AS IF
WERE COMPLETING THE FORM.
1.
Since
, has the child’s marital status changed?
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)
Form SSA-3989-OCR-SM (07-2006)
Yes
No
Single
/
3989 1
3989
EO991A
2.
Since
, has the marital status of the parents living with the child
changed?
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
Date marital status changed (Month/Year)
3.
Yes
No
Yes
No
Single
/
Does the child live with either of his/her parents?
If “no,” go to Question 4.
Since
, 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:
Date Moved In
None - N/A
Spouse
Mother
Father
Brother
Other Relative
Other
/
/
Date Moved Out
Sister
/
b. Name:
Relationship:
Date Moved In
None - N/A
Spouse
Mother
Father
Brother
Other Relative
Other
/
/
Date Moved Out
Sister
/
c. Name:
Relationship:
Date Moved In
/
/
None - N/A
Spouse
Mother
Father
Brother
Other Relative
Other
/
Form SSA-3989-OCR-SM (07-2006)
/
Date Moved Out
3989 2
Sister
/
/
4.
Yes
Since
, 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,” please give:
No
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:
Zip Code:
State:
Date the Person Moved (Month/Year)
5.
/
List all the people who live in the same household with the child.
a. Name:
Relationship:
Date of Birth
None-N/A
Spouse
Mother
Father
Brother
Other Relative
Other
/
Social Security
Number
/
Sister
–
–
b. Name:
Relationship:
Date of Birth
None-N/A
Spouse
Mother
Father
Brother
Other Relative
Other
/
Form SSA-3989-OCR-SM (07-2006)
/
Social Security
Number
3989 3
Sister
–
–
Question continues on the next page
3989
EO991B
c. Name:
None-N/A
Relationship:
Spouse
Mother
Father
Brother
Other Relative
Other
/
Date of Birth
Sister
Social Security
Number
/
–
–
d. Name:
None-N/A
Relationship:
Spouse
Mother
Father
Brother
Other Relative
Other
/
Date of Birth
Sister
Social Security
Number
/
–
–
e. Name:
None-N/A
Relationship:
Spouse
Mother
Father
Brother
Other Relative
Other
/
Date of Birth
Sister
Social Security
Number
/
–
–
If you need more space use the REMARKS Section on page 11.
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
, 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)
a.
Hospital
/
Date Discharged
(Month/Day/Year)
/
Nursing Home
a.
Jail
Other Institution
/
/
None-N/A
Name and Address of Institution:
Form SSA-3989-OCR-SM (07-2006)
3989 4
Question continues on the next page
Date Entered
(Month/Day/Year)
/
b.
Hospital
Date Discharged
(Month/Day/Year)
/
b.
Nursing Home
Jail
/
/
Other Institution
None-N/A
Name and Address of Institution:
8.
Since
, 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)
/
a.
Date(s) Returned
(Month/Day/Year)
/
/
a.
Where Did the Child Go?
N/A
/
N/A
/
b.
/
/
b.
/
Yes
9.
Since
No
, 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:
Example:
If you have $600, it would
be printed like this.
$
, 6
0
0 .
SHOW DOLLARS ONLY
Form SSA-3989-OCR-SM (07-2006)
3989 5
Question continues on the next page
3989
EO991C
Mother
Father
Child
Name of Employer/
Address
Gross Wages
(Before Any Deductions)
Amount: $
,
Weekly
Paid:
Dates of Employment
.
BiWeekly
Monthly
Amount: $
,
Weekly
Paid:
.
BiWeekly
Monthly
Amount: $
Paid:
,
Weekly
.
BiWeekly
Monthly
From:
/
/
To:
/
/
From:
/
/
To:
/
/
From:
/
/
To:
/
/
Yes
No
Yes
No
Is the child a student?
10.
Since
, 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?
If the answer to the question is “no,” go to Question 11.
If the answer to the question is “yes,” please give:
N/A
N/A
Child
N/A
Father
Mother
Type of Business
Total Gross Income for Last Year
$
,
.
$
,
.
$
,
.
Net Income for Last Year
$
,
.
$
,
.
$
,
.
Estimated Gross Income for this
Year
$
,
.
$
,
.
$
,
.
Estimated Net Income for this
Year
$
,
.
$
,
.
$
,
.
Form SSA-3989-OCR-SM (07-2006)
3989 6
11.
Since
, 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:
Yes
No
A. Private pensions or annuities (other than 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
Mother
Father
Child
Type of Received by
Income
(choose
from letters
above)
$
,
Weekly
Dates Received or Expected
.
BiWeekly
From:
/
To:
/
Monthly
Form SSA-3989-OCR-SM (07-2006)
3989 7
Source
(Name/Address of
Person, Bank, Company
or Organization)
N/A
Question continues on the next page
Amount /
How Often
Mother
Father
Child
Type of Received by
Income
(choose
from letters
above)
$
,
Weekly
Dates Received or Expected
.
BiWeekly
From:
/
To:
/
From:
/
To:
/
From:
/
To:
/
From:
/
To:
/
Monthly
$
,
Weekly
.
BiWeekly
Monthly
$
,
Weekly
.
BiWeekly
Monthly
$
,
Weekly
.
BiWeekly
Monthly
Source
(Name/Address of
Person, Bank, Company
or Organization)
N/A
N/A
N/A
N/A
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?
Form SSA-3989-OCR-SM (07-2006)
3989 8
Question continues on the next page
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 and Address of Bank, Company or Organization
Total Value of Each
Mother
Father
Child
Name of Owner or
Each Item Co-Owner
(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.)
If the answer to the question is “no,” go to Question 15.
If the answer to the question is “yes,” please give:
Form SSA-3989-OCR-SM (07-2006)
3989 9
Yes
No
Question continues on the next page
Tax Assessed Value,
if known
Estimated Current
Market Value
Mother
Father
Child
Owner or
Co-Owner
Amount of Mortgage
Payment, if any
Amount Owed on this
Property
$
,
. $
,
. $
,
. $
,
.
$
,
. $
,
. $
,
. $
,
.
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
, has the child had any change in health insurance coverage or other
insurance that pays for medical bills?
(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.
None-N/A
If the answer to the question is “yes,” please explain:
16.
If the child was disabled before age 22, does the child have a parent who is age 62 or older
or disabled, or deceased?
17.
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
Form SSA-3989-OCR-SM (07-2006)
Other (write in name of language):
3989 10
Yes
No
Yes
No
WE ARE REQUIRED BY LAW TO ASK THE FOLLOWING QUESTIONS OF ALL SSI RECIPIENTS
18.
a. Has the child been convicted of, or charged with a crime, or an attempt to commit
a crime, which is a felony, or in jurisdictions that do not define crimes as felonies, is
punishable by death or imprisonment for a term exceeding 1 year regardless of the actual
sentence imposed?
If “yes,” in which state did this occur?
Yes
No
Yes
No
Answer b.
b. Since
, has a warrant been issued for the child’s arrest because the child
was charged or convicted of a crime that carries a sentence of over 1 year, or because the
child violated a condition of the child’s probation or parole under Federal or State law?
If “yes,” explain below (provide warrant information, if available):
19.
a. Has the child been subject to a condition of parole or probation under Federal or State
law?
b. Since
, has the child violated a condition of your parole or probation?
If “yes,” explain below (provide warrant information, if available).
Child
20.
Yes
a. Since
, 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?
Father
No
Yes
b. Since
, 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:
Form SSA-3989-OCR-SM (07-2006)
3989 11
,
.
No
Mother
Yes
No
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
know that anyone who makes or causes to be made a false statement or representation of material fact in application or
for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal or
State law or both. I affirm that all information I have given in this document is true.
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
–
–
FO
FO1
Area Code & Telephone Number (Where you can be reached)
(
)
–
None
FOR SSA USE ONLY
WBDOC
WBDOC1
Form SSA-3989-OCR-SM (07-2006)
WBDOC2
WBDOC3
3989 12
FO2
FO3
| File Type | application/pdf |
| File Title | 3989.indd |
| Author | Jack Phillips |
| File Modified | 2006-11-06 |
| File Created | 2006-07-10 |