Form SSA-760-F4 Certificate of Support

Form SSA-760 (10-2017) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 6
OMB No. 0960-0001

Certificate of Support
(There is a time limitation for the filing of this certificate. It should be filed promptly.)
DO NOT WRITE IN THIS SPACE

Enter Name of Wage Earner of Self-Employed Person
(Herein referred to as the "worker")

Enter His(Her) Social Security Number

Part 1 - Identity
I intend that this certificate shall be considered as part of my application for insurance benefits which may be payable to me under
the provisions of Title II of the Social Security Act, as amended. I hereby certify that I was receiving at least one-half my support
from the worker at the time specified in Item 8 of this Certificate and submit the following information as proof of the facts.
1.

Enter your full name (Print or write clearly)

2.

Enter your date of birth (Month, Day, and Year)

4.

Show your relationship to the worker. ( Husband, wife, widower, widow, mother, father, stepmother, adopting father, etc.)
(If you indicate that you are the husband, wife, widower, or widow, Skip to item 9.)

5.

If the worker has another living parent (other than yourself) enter the following information regarding the other parent

3. Enter your Social Security number (If none, write "None")

Full Name
Address

6.

Relationship to Worker (Father,
mother, stepfather, etc.)

If you are a stepparent:
When did you marry the worker's father or mother?

7.

Age

Where did this marriage take place?

If you are an adopting parent:
When did you adopt the worker?

Where did this adoption take place?

Form SSA-760 (10-2017) UF

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Part 2 - Support
8.

9.

Month

Question 9 through 19 apply to your income and support for the
12-month period ending:
This form must be filed no later than:

Date:

Enter the total amount of the worker's income during the 12-month
period shown in item 8:

Amount: $

Day

Year

10. (a) Did you own the dwelling in which you lived during the 12-month period show in item 8?
Yes

No

(If "Yes," go on to item 11.)

(If "No," enter below the name and relationship of the person who owned the
dwelling in which you lived and complete (b) and if appropriate, (c) and (d).)

Name of Owner

Relationship to you (If none, write "None.")

(b) Did you pay either rent or all the costs of maintaining
the property (such as repairs, mortgage, taxes, etc.)?

Yes

No

(If "Yes," skip (c) and
(d) and go to item 11)

(If "No," answer (c)
and (d).)

(c) List below each person who paid the rent or the costs of maintaining the property, what each paid for, and how much:
Person Who Paid

Item Paid For

Amount
$
$
$
$

(d) What was the monthly rental value of the house?

$

11. Enter the following about the worker and any other person who lived with you or who contributed to the support of your
household during the 12-month period shown in item 8. Include contributions for support, payments for room and board,
household expenses, clothing, insurance and medical expenses, gifts, etc.
Date and Amount of Last
Each Dates Each Total Amount
Relationship Dates
Contribution
Name
Lived
With
Contributed
to You
Contributed
You
By Each
Date
Amount
$

$

$

$

$

$

$

$

12. If any of the contributions to you stopped before the end of the period, explain why:

Form SSA-760 (10-2017) UF

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13. (a) Did you furnish room and board to anyone who lived with you during the 12-month period shown in item 8?
Yes (If "Yes," complete (b).)
(b)

No (If "No," go on to item14)

Person to Whom You Furnished
Room and Board

Dates
Furnished

Cost or Estimated Cost of Room
and Board (Monthly)

14. (a) Did you receive any income during the 12-month period shown in item 8 from any of the sources shown below?
Yes (If "Yes," complete (b) below.)

No (If "No," go on to item 15.)

(b)
Source

Income

Wages, salary, commissions, etc. (Show gross
amount before deductions for taxes, FICA
contributions, insurance, etc.)
Pensions, annuities, insurance (including Social
Security benefits)
Stocks, bonds, securities, etc.

Date You Last Received
Income and Amount
Date
Amount

$

$

$

$

$

$

15. Did you or any member of the household receive any kind of public or private aid during the 12-month period shown
in item 8?
Yes (If "Yes," give the following information)
No (If "No," go on to item16.)
(Include payments for room and board, for household
expenses, for clothing, for medical expenses, etc.)
Name of Person For Whom Aid
Was Given

Name and Address of
Agency

Total Amount
Contributed by Each

Date and Amount of Last
Contribution
Date
Amount

$

$

$

$

$

$

16. Complete this item if you deposited or withdrew funds from a bank account during the 12-month period shown in item 8.
Total Deposits Made
During Period

Owner(s) of Account

Total Withdraws Made
During Period

$

$

$

$

$

$

Form SSA-760 (10-2017) UF

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17. Give the nature and amount of any other funds which were used for support (or saved) during the 12-month period shown
in item 8.

18. State the nature and amount of your debts, if any, at the end of the period shown in item 8. (If none, write "None.")
Description

Date Incurred

Amount
$

$

$
19. State any additional facts which you believe tend to show that you were receiving at least one-half of your support from the
worker during the period shown in item 8.

Form SSA-760 (10-2017) UF

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Remarks: (This space is for more detailed answers to the above questions, if necessary. If you need more space attach a
separate sheet.)

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 statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.

Signature of Applicant
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number (Area Code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Enter name of County (if any) in which
you now live

Witnesses are only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant making the request must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

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

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

Form SSA-760 (10-2017) UF

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Privacy Act Statement
See revised
Collection and Use of Personal Information Privacy Act
Statement
Sections 202(h) and 202(k)(5)(A) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination of eligibility for Social
Security benefits.
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 eligibility. 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 list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notice 60-0089, entitled Claims Folders Systems. Additional information about this and
other system of records notices and our programs is available online at www.socialsecurity.gov or at your
local Social Security office.
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 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 control number. We
estimate that it will take about 30 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.