SSA-781 (current)

Form Approved
OMB No. 0960-0019

Social Security Administration

CERTIFICATE OF RESPONSIBILITY FOR WELFARE AND CARE OF CHILD NOT IN APPLICANT'S CUSTODY

All items on this form requiring an answer must be answered or marked "Unknown."
PRIVACY ACT STATEMENT:
Collection and Use of Personal Information
Sections 202(b) and (g) [42 U.S.C. 402(b) and (g)] of the Social Security Act authorize us to collect this information. We will use the information you
provide to confirm past and continuing entitlement to benefits and to determine whether such benefits are subject to suspension or termination. The
information you provide on this form is voluntary. However, failure to provide all or part of the requested information is cause for us to suspend your
benefit payments.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following: 1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage; 2. To comply with Federal laws requiring the release of information from Social Security records (e.g.,
to the Government Accountability Office, General Services Administration, National Archives Records Administration, and the Department of Veterans
Affairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and 4. To
facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other
Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for
Federally-funded and administered benefit programs for repayment of payments or delinquent debts under these programs. The law allows us to do this
even if you do not agree to it.
A complete list of routine uses for this information is available in our System of Records Notice entitled, Claims Folder System, 60-0089. This notice,
additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at any
Social Security office.
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 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. You can find your local Social Security office through SSA's website at
www.socialsecurity.gov. Offices are also 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 only comments relating to our time estimate to this address, not the completed form.
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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.

FULL NAME OF CHILD

2.

DATE
CHILD
LEFT
YOUR
HOME

How Long
From today will the
child be
away from
you?

REASON CHILD
LEFT YOUR HOME

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

(a) If you contribute to the support of any child named in item 1 above, give the following information:
AMOUNTS CONTRIBUTED

FIRST NAME OF CHILD

HOW OFTEN YOU CONTRIBUTE

$
$
$
$
(b) If you are not contributing 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 (08-2010) EF (08-2010) Destroy Prior Editions

3.

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

4.

VISIT

SEND CLOTHING

MAKE OTHER
GIFTS

WRITE
LETTERS

OTHER
(DESCRIBE)

Do you give the person or persons with whom the child or children have been placed
Yes
No
instructions for the care of such child or children?
If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are
carried out.

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

SIGN
HERE

DATE (Month, day, year)

TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY
(include area code)

u

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 (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-781 (08-2010) EF (08-2010)

2. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)