Form Ssa-781 - Certificate Of Responsibility For Welfare And Care Of Child Not In Applicant'S Custody

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Form Approved
Social Security Administration
OMB No. 0960-0019
CERTIFICATE OF RESPONSIBILITY FOR WELFARE
AND CARE OF CHILD NOT IN APPLICANT'S CUSTODY
All items on this form requiring an answer must be answered or marked "Unknown."
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
I make this statement in support of my application for insurance benefits payable under Title II of the Social Security Act,
as amended.
1. Give the following information about all unmarried children of the above wage earner or self-employed person who are not
living with you and are: (a) under age 16, or (b) age 16 or over, with a disability that began before age 22. Include natural
children, adopted children, stepchildren, and dependent grandchildren or step-grandchildren.
How Long
NAME, ADDRESS, TELEPHONE
DATE CHILD
From today
NUMBER AND RELATIONSHIP
REASON CHILD
FULL NAME OF CHILD
LEFT YOUR
will the child
(TO CHILD) OF PERSON
LEFT YOUR HOME
HOME
be away
WITH WHOM CHILD
from you?
IS NOW LIVING
2. (a) If you contribute to the support of any child named in item 1 above, give the following information:
FIRST NAME OF CHILD
AMOUNTS CONTRIBUTED
HOW OFTEN YOU CONTRIBUTE
$
$
$
$
(b) If you are not contributing to the support of any child named in 1 above, give name of child and state why you are not
doing so.
Form SSA-781 (06-2015) UF (06-2015)
Page 1
Destroy Prior Editions

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