Form Ssa-781 - Certificate Of Responsibility For Welfare And Care Of Child Not In Applicant'S Custody Page 2

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3. State how often you do any of the things shown below for any child named in item 1.
SEND
MAKE OTHER
FIRST NAME OF CHILD
VISIT
WRITE LETTERS OTHER (DESCRIBE)
CLOTHING
GIFTS
4. Do you give the person or persons with whom the child or children have been placed
Yes
No
instructions for the care of such child or children?
If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are carried out.
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
DATE (Month, day, year)
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)
Telephone Number(s) At Which You May Be
Contacted During The Day (include area code)
MAILING ADDRESS (Number and street, P.O. Box, or Rural Route)
CITY AND STATE
ZIP CODE
Enter Name of County (if any) In Which You Now Live
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant 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)
Page 2
Form SSA-781 (06-2015) UF (06-2015)

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