SSA-1383-FC Report to Social Security Administration by Student Outs

Form Approved
OMB No. 0960-0088
Our address is:
Social Security Administration
P.O. Box 1756
Baltimore, Maryland 21203 U.S.A.

Social Security Administration

REPORT TO SOCIAL SECURITY ADMINISTRATION
BY STUDENT OUTSIDE THE UNITED STATES
(Use this form ONLY when there is a change to be
reported for a United States Social Security beneficiary)

PRINT NAME OF STUDENT ABOUT WHOM REPORT IS MADE SOCIAL SECURITY CLAIM NUMBER ON WHICH
BENEFITS ARE PAID. It is a nine digit number
(000-00-0000) followed by a letter or a number, such as
C, C1, HC, HC1. Your report cannot be processed
without the correct claim number.
LETTER
If you need help in completing this form or additional information about your benefits, you may contact the nearest U.S.
Social Security office, Embassy or Consulate. If you live in the Philippines, you may contact the U.S. Veterans
Administration Regional Office in Manila.
Please MAIL THIS REPORT DIRECTLY TO:

Social Security Administration
P.O. Box 1756
Baltimore, Maryland 21203 U.S.A.

Be sure to affix proper postage on the envelope.
CHECK OR FILL IN ONLY THE INFORMATION BEING REPORTED
1.

CHANGE OF ADDRESS (Print new address after signature below)
More than 6 mos.
6 mos. or less
Check if change is for:

2.

EMPLOYMENT (As employee or as self-employed person)

DATE EMPLOYMENT BEGAN

3.

MARRIAGE

DATE OF MARRIAGE

4.

NO LONGER ATTENDING ANY SCHOOL (Do NOT report this item merely because school MONTH, DAY, YEAR
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 full-time basis was
MONTH, DAY, YEAR
REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
The last day that I attended school on a full-time basis was

5.
6a.

MONTH, DAY, YEAR

CHANGED SCHOOLS
I have arranged to change schools effective
I am (will be) attending
full-time
part-time

b.

NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records, such as type of
school, branch or campus and division)

c.

TYPE OF SCHOOL
ELEMENTARY or SECONDARY SCHOOL

d.

STUDENT IDENTIFICATION NUMBER

STUDENT'S SOCIAL SECURITY NUMBER

e.

DATE SCHOOL YEAR WILL END

MONTH, YEAR

7a.
b.

UNIVERSITY

OTHER (explain)

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on

MONTH, DAY, YEAR

NAME AND ADDRESS OF EMPLOYER

Form SSA-1383-FC (XX-2015)
Destroy Prior Editions

(OVER)

8.

9.

DATE OF INCARCERATION
INCARCERATION FOR CONVICTION OF A FELONY
Student is confined in a jail, prison, or other institution or correctional facility, based (MONTH, DAY, YEAR)
on a conviction for a felony committed after October 19, 1980.
DATE OF ARREST WARRANT
WARRANT ISSUED FOR STUDENT'S ARREST
(MONTH, DAY, YEAR)
Do you have an unsatisfied warrant for your arrest for a crime or attempted crime
of flight to avoid prosecution or confinement or escape from custody?

SIGNATURE OF PERSON MAKING THIS REPORT

DATE SIGNED

MAILING ADDRESS (NUMBER AND STREET, APT. NO.)
CITY OR TOWNSHIP

POSTAL CODE

COUNTRY

Notice: This report is authorized in order to confirm continuing eligibility to Social Security benefits as provided by law
(section 202(d) of the U.S. Social Security Act, as amended (42 United States code 402(d)).
WHAT TO REPORT
The kinds of events that you must report to Social Security are listed below. Check any of the events that apply to you and
fill in any other information requested about the event.
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 you.
Also, if you conceal or fail to disclose a report event with an intent to fraudulently obtain benefits 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.
OTHER USES WHICH MAY BE MADE OF THE INFORMATION ON THIS REPORT
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d), 203(f), and 205(a) of the Social Security Act, as amended, authorize us to collect this information. We will
use the information you provide to determine continued entitlement of student benefits and to determine correct benefit
amounts.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent an
accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding benefits
entitlement. However, we may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act
Systems of Records Notice 60-0089, entitled, Claims Folder System. Additional information about this and other system of
records notices and our programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs. Matching
programs compare our records with records kept by other Federal, State or local government agencies. We use the
information from these programs to establish or verify a person's eligibility for federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
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 (OMB) 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.
Form SSA-1383-FC (XX-2015)