Current SSA-1383

Form Approved
OMB No. 0960-0088

TOE 240

SOCIAL SECURITY ADMINISTRATION

STUDENT REPORTING FORM
Use this form only when there is a change to be reported.
PRINT NAME OF STUDENT

u

SOCIAL SECURITY CLAIM NUMBER
ON WHICH BENEFITS ARE PAID
It is a nine-digit number (000-00-0000) followed by
letter(s) C or HC. We cannot process your report
without the correct claim number.

LETTER(S)

u

1.

2.

CHANGE OF ADDRESS (Print new address at bottom of form.)
If the Social Security Administration is sending your payments to your financial
organization, do you want this to continue?
WORKING AND WILL EARN OVER THE EXEMPT AMOUNT - $
year (specify)

YES
MONTH AND YEAR

for the

(specify)

NO

a. I am working for wages of more than $
a month or performing
{
substantial services in self-employment beginning with the month of . . . . . . .
AMOUNT
FILL IN BOTH BOXES
y
b. I estimate that my total earnings for this taxable year will be . . . . . . . . . . . . . . . . $
3.

MARRIAGE OF STUDENT

DATE OF MARRIAGE
(MONTH, DAY, YEAR)
u

4.

5.

6a.

b.

NO LONGER ATTENDING ANY SCHOOL
(Do NOT report this item merely because school year ended if you intend to resume
full-time attendance after a vacation period of not more than 4 full calendar
months.) The last day that I attended school on a full-time basis was
REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
The last day that I attended school on a full-time basis was
CHANGED SCHOOLS
I have arranged to transfer schools effective
I am (will be) attending
full-time
part-time
NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records.)

c. TYPE OF NEW SCHOOL
Secondary (High school level or below)

MONTH, DAY, YEAR

u
MONTH, DAY, YEAR

u
MONTH, DAY, YEAR
u

Post-secondary (College, Junior
College, Trade or Vocational)

d. STUDENT IDENTIFICATION NUMBER

OTHER

(specify)

STUDENT'S SOCIAL SECURITY NUMBER

e. DATE SCHOOL YEAR WILL END

MONTH, YEAR
u

7a.

b.

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL

MONTH, DAY, YEAR

I began attending school as part of my job on
NAME AND ADDRESS OF EMPLOYER

u

8.

INCARCERATION FOR CONVICTION OF A CRIME
Student is confined in a jail, prison, or other correctional institution
based on a conviction of a crime.

9.

WARRANT ISSUED FOR STUDENT'S ARREST

DATE OF INCARCERATION
(MONTH, DAY, YEAR)
u

An unsatisfied warrant was issued for your arrest for a crime or attempted crime of
flight to avoid prosecution or confinement or escape from custody.

DATE OF ARREST WARRANT
(MONTH, DAY, YEAR)

SIGNATURE OF PERSON MAKING THIS REPORT

u
NUMBER AND STREET, APT. NO., P.O. BOX OR RURAL ROUTE
CITY
DATE SIGNED

STATE
AREA CODE & TELEPHONE NO. (IF ANY)

Form SSA-1383 (02-2012) EF (02-2012) Destroy Prior Editions

ZIP CODE
ENTER NAME OF COUNTY, IF ANY, IN WHICH YOU LIVE

Privacy Act Statement
Collection and Use of Personal Information

HOW TO REPORT
There are three ways to report:
1. PHONE Social Security and explain the change.
Telephone Number (

)

(Area Code)

2. VISIT any Social Security office.

3. MAIL this form to any Social Security office.
MAKE SURE YOU FILL IN THESE NECESSARY DETAILS
ON THE REVERSE SIDE OF THIS FORM:
•

NAME of student about whom the report is made;

•

The correct CLAIM NUMBER under which the
benefits are payable;

•

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 kinds of events that you must report to Social Security
are listed on the reverse side of this form. Check any of the
events that apply to you and fill in any other information
requested about the event. If you need more information to
fill out this form, please read "Social Security: What You
Need to Know When You Get Retirement or Survivors
Benefits" and/or "Social Security: What You Need to Know
When You Get Disability Benefits." If you do not have these
publications, or if you want help in making a report,
get in touch with any Social Security office for help.

FAILURE TO REPORT
If you do not report events as shown on this form, 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 to you.
Also, if you conceal or fail to disclose a reporting event
with an intent to obtain benefits fraudulently either in a
greater amount than is due or when no payment is
authorized, you may be FINED, IMPRISONED, or both as
provided in section 208 of the Social Security Act.

Sections 202(d) and 203 (f) of the Social Security Act as
amended [42 U.S.C. 402(d) and 403(f)] and Title 20 CFR
404.415, 404.434, 404.435 (b) (2), 404.367, 404.368, and
422.135, authorize us to collect this information. The
information you provide will help us determine your
entitlement to benefits. The information you provide is
voluntary. However, your failure to provide all or part of the
requested information could prevent us from making an
accurate and timely decision concerning your entitlement to
benefits.
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 agencies can be
used to establish or verify a person’s eligibility for
Federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these
programs.
A complete list of routine uses for this information is available
in our System of Records Notice entitled, Claim Folders
Systems, 60-0089. The notice, additional information
regarding this form, and information regarding our system and
programs, are available on-line at www.socialsecurity.gov or
at any local Social Security office.

PAPERWORK REDUCTION ACT
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 6
minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our
time
estimate
above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

Use this form ONLY when there is a change to report to Social Security.
Form SSA-1383 (02-2012) EF (02-2012)