SSA-4-INST - Current

Form SSA-4-INST (01-2017) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0010

REPORTING RESPONSIBILITIES FOR CHILD'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID AND IN
POSSIBLE MONETARY PENALTIES

•

You or any child changes the mailing address for checks
or residence. To avoid delay in receipt of checks you
should ALSO file a regular change of address notice with
your post office.

•
•

Any child's citizenship or immigration status changes.

•

Any beneficiary dies or becomes unable to handle
benefits.

•

Work Changes - On your application you told us

•

Change in Marital Status - Marriage, divorce, or
annulment of marriage. You must report marriage even if
you believe that an exception applies.

•

Disability Applicants - In addition to the applicable
reporting requirements listed above:
1. The disabled adult child returns to work (as an
employee or self-employed) regardless of
amount of earnings.
2. The disabled adult child's condition improves.

Any beneficiary goes outside the U.S.A. for 30
consecutive days or longer.

expected total earnings
(Name of Child)
for

to be $

.

(Year)
(is)

(is not) earning

(Name of Child)
wages of more than $

a month.
(is)

(is not) self-

(Name of Child)

An agency in your State that works with us in administering
the Social Security disability program is responsible for
making the disability decision on the child's claim. In some
cases, it is necessary for them to get additional information
about the child's condition or to arrange for the child to have
a medical examination at Government expense.
HOW TO REPORT
You can make your reports by telephone, mail, or in person,
whichever you prefer.
If you are awarded benefits, and one or more of the above
change(s) occur, you should report by:

employed and rendering substantial services in a trade
or business.

•

Visiting the section "What You Can Do Online" at
our web site at www.socialsecurity.gov;

(Report AT ONCE if this work pattern changes)

•

Calling us TOLL FREE at 1-800-772-1213;

•

Custody Change - Report if a child for whom you are
filing, or who is in your care dies, leaves your care or
custody, or changes address.

•

If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or

•

The child age 13 or older has an unsatisfied felony or
arrest warrant for more than 30 continuous days for flight
to avoid prosecution or confinement, escape from
custody, or flight-escape.

•

Calling, visiting or writing your local Social Security
office at the phone number and
address above.

•

A student, age 18 or over, stops attending school,
reduces school attendance below full-time, changes
schools, or is paid by an employer to attend school.

•

If the worker and stepchild's parent divorce. Benefits are
not payable to a stepchild beginning with the month after
the month the worker and the stepchild's parent divorce.
Promptly return any benefit payment received on behalf of
the stepchild for the months after the month the divorce
becomes final.

•

The child is confined for more than 30 continuous days to
a jail, prison, penal institution or correctional facility for
conviction of a crime or confined to a public institution by
a court order in connection with a crime.

For general information about Social Security, visit our web
site at www.socialsecurity.gov.
For those under full retirement age, the law requires that a
report of earnings be filed with SSA within 3 months and 15
days after the end of any taxable year in which the child
earns more than the annual exempt amount. You may
contact SSA to file a report for the child. Otherwise, SSA
will use the earnings reported by the child's employer(s)
and the child's self-employment tax return (if applicable) as
the report of earnings required by law, to adjust benefits
under the earnings test. It is your responsibility to ensure
that the information you give concerning the child's earnings
is correct.

Form SSA-4-INST (01-2017) UF

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NOTICE ABOUT DOCUMENTS
We recommend that you keep copies of all documents you submitted to us.
We are returning the documents you submitted with this claim.
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 205, 223, 1818, 1836, and 1840 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely decision on any claim filed, or could result in the loss of
benefits.
We will use the information you provide to determine eligibility for monthly benefits or insurance coverage
and to authorize payments to the children of retired, disabled, or deceased workers. We may also share
your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash
income maintenance or health maintenance programs (including programs under the Act).
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the
efficient administration of its programs. We contemplate disclosing information under this routine
use only in situations in which SSA may enter a contractual or similar agreement with a third party
to assist in accomplishing an agency function relating to this system of records.
3. To the Centers for Medicare & Medicaid Services, for the purpose of administering Medicare Part
A, Part B, Medicare Advantage Part C, and Medicare Part D.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089,
entitled Claims Folder System, and 60-0321, entitled Medicare Database (MDB) File. Additional information
and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
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 12 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.