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

Form SSA-1383-FC (06-2018)
8.OINCARCERATION FOR CONVICTION OF A �lsb0N� (:f( / tn�
Student is confined in a jail, prison, or other instit1:1tion or correctional �ei�ased
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on a conviction for a felony eommitteel after Oetober 19, 1989.:_
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9. WARRANT ISSUED FOR STUDENrS ARREST
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?

□

CITY OR TOWNSHIP

DATE OF ARREST WARRANT
(MM/DD/YYYY)
DATE SIGNED

SIGNATURE OF PERSON MAKING THIS REPORT
MAILING ADDRESS (NUMBER AND STREET, APT. NO.)

Page 2 of 2
DATE OF INCARCERATION
(MM/DD/YYYY)

I

POSTAL CODE

I

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

See Revised Privacy Act &

Privacy Act Statement
Collection and Use of Personal Information PRA Statements attached.
Sections 202(d), 203 (h), and 205(a) 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.
We will use the information to determine your entitlement and benefits. We may also share your information for the
following purposes, called routine uses:
1. To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representative
payees to the extent necessary to pursue Social Security claims and to representative payees when the information
pertains to individuals for whom they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they serve as payees; and
2. To the Department of State and its agents for administering the Act in foreign countries through facilities and services of
that agency.
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
Folders System. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity,gov/foia/bluebook.
Papeiwork 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 (0MB) 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.

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 202(d), 203(h), and 205(a) 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.
We will use the information to determine your entitlement and benefits. We may also share your
information for the following purposes, called routine uses:
•

To the Department of State, for administration of the Social Security Act in foreign
countries through services and facilities of that agency; and

•

To claimants, prospective claimants (other than the data subject), and their authorized
representatives or representative payees, to the extent necessary to pursue Social Security
claims; to representative payees, when the information pertains to individuals for whom
they serve as representative payees, for the purpose of assisting us in administering
representative payment responsibilities under the Social Security Act; and to
representative payees, for the purpose of assisting them in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they
serve as payees.

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 Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all our SORNs,
is available on our website at www.ssa.gov/privacy.

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 regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.