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Form Approved

OMB No. 0960-0003

REPORTING RESPONSIBILITIES FOR MOTHER'S OR FATHER'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 change your mailing address for checks or

You begin to receive a government pension or

residence. (To avoid delay in receipt of checks you

annuity (from the Federal government or any State

should ALSO file a regular change of address notice

or any political subdivision thereof) or your pension

with your post office.)

or annuity amount changes.

You have an unsatisfied warrant for your arrest for

Your citizenship or immigration status changes.

a crime or attempted crime that is a felony (or, in

jurisdictions that do not define crimes as felonies, a

crime that is punishable by death or imprisonment

for a term exceeding 1 year.)

You go outside the U.S.A. for 30 consecutive days

or longer.

You have an unsatisfied warrant for a violation of

probation or parole under Federal or State law.

Any beneficiary dies or becomes unable to handle

benefits.

WORK AND EARNINGS

For those under full retirement age, the law requires

Work Changes - On your application you told us

that a report of earnings be filed with SSA within 3

you expect total earnings for

to be

months and 15 days after the end of any taxable year

in which you earn more than the annual exempt

amount. You may contact SSA to file a report.

Otherwise, SSA will use the earnings reported by your

You

(are)

(are not) earning wages of more

employer(s) and your self-employment tax return (if

than $

a month.

applicable) as the report of earnings required by law

and adjust benefits under the earnings test. It is your

responsibility to ensure that the information you give

You

(are)

(are not) self-employed rendering

concerning your earnings is correct. You must furnish

substantial services in your trade or business.

additional information as needed when your benefit

adjustment is not correct based on the earnings on

your record.

(Report AT ONCE if this work pattern changes)

HOW TO REPORT

Change of Marital Status - Marriage, divorce,

You can make your reports by telephone, mail, or in

annulment of marriage. You must report marriage

person, whichever you prefer.

even if you believe that an exception applies.

If you are awarded benefits, and one or more of the

above change(s) occur, you should report by:

Custody Change or Disability Improves - Report if a

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

person for whom you are filing, or who is in your

If you are deaf or hearing impaired, calling us TOLL

care dies, leaves your care or custody, changes

FREE at TTY 1-800-325-0778; or

address, or, if disabled, the condition improves.

Calling, visiting or writing your local Social Security

office at the phone number and address shown on

your claim receipt.

You are confined to jail, prison, penal institution or

correctional facility for conviction of a crime or you

are confined to a public institution by court order in

For general information about Social Security, visit our

connection with a crime.

web site at

NOTICE ABOUT DOCUMENTS

We recommend that you keep all documents you submitted to us.

We are returning the documents you submitted with this claim.

Form SSA-5-INST (07-2009) EF (07-2009)

Destroy Prior Editions

Form Ssa-5-Inst - Reporting Responsibilities For Mother'S Or Father'S Insurance Benefits

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