Revised SSA-781 (with marked non-substantive change)

Form Approvad
OMB No. 0960-0019

Social Security Administration
CERTIFICATE OF RESPONSIBILITY FOR WELFARE
AND CARE OF CHlLD NOT IN APPLICANT'S CUSTODY

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All items on this form requiring an answer must be answered or marked *Unknown."

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SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

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--- -----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).
DATE

Remove Bracket

FULL NAME OF CHILD

Eg

YOUR
HOME

How Long
From today
child
willbe
the
away from
you?

REASON CHlLD
LEFT YOUR HOME

NAME. ADDRESS, TELEPHONE
NUMBER AND RELATIONSHIP
(TO CHILD) OF PERSON
WITH WHOM CHILD
IS NOW LIVING

2' (a) If you contribute t o 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 bontributing 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 (10-1983) EF (10-2000)

3'

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

4.

VISIT

SEND CLOTHING

MAKE OTHER
GIFTS

WRITE
LETTERS

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?

OTHER
(DESCRIBE)

Yes

NO

If "Yes," explain what those instructions are, h o w often you give them, and what you do t o b e sure they are
carried out.

I Know rnar anyone wno (a) maKes or causes ro De maae any ralse sraremenr or represenrarlon or a marerlal racr Tor use In
determining a right t o or the amount of any payment, or in determining an individual's disability, under Title II of the Social
Security Act, or (b) who, having received a payment for the use and benefit of another person, know~nglyand willfully uses such
payment for other than the person for whom it is received, under the Social Security Act, commits a crime Punishable under
Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.

SIGNATURE OF APPLICANT
SlGNATURE (First Name, Middle Initial, Last Name) (Write in ink) .

DATE (Month, day, year)

MAY BE CONTACTED DURING THE DAY
linclude area codel

SIGN
HERE
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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 (XI above. If signed by mark (XI, 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 ZlP Code)

ADDRESS (Number and street, City, State and ZIP Code)
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Form SSA-78 1 ( 10-1983) EF ( 10-2000)

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 5 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. The office is 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&o comments relating to our time estimate to this
address, not the completed form.