Form SSA-1383-FC (03-2017)
Page 2 of 2
DATE OF INCARCERATION
INCARCERATION FOR CONVICTION OF A FELONY
(MONTH, DAY, YEAR)
Student is confined in a jail, prison, or other institution or correctional facility, based
on a conviction for a felony committed after October 19, 1980.
DATE OF ARREST WARRANT
WARRANT ISSUED FOR STUDENT'S ARREST
(MONTH, DAY, YEAR)
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?
SIGNATURE OF PERSON MAKING THIS REPORT
MAILING ADDRESS (NUMBER AND STREET, APT. NO.)
CITY OR TOWNSHIP
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
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:
1. To third party contacts where necessary to establish or verity information provided by representative payees or
payee applicants; and
2. 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.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
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
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 relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.