Fillable Reporting Changes That Affect Your Social Security Payment printable pdf download

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0073

REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT

USE THIS FORM WHEN THERE IS A CHANGE TO BE REPORTED. ONLY COMPLETE THE ITEM(S) THAT HAVE CHANGED.

PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE

SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID

LETTER

You should include the letter or letter and number A, B, B2 C, C1,

D, E, F, or H.

Your report cannot be processed without the correct claim number.

DO YOU GET SSI BENEFITS? (Check one)

YES

CHANGE OF ADDRESS (Print new address at bottom)

If Social Security sends your payments to your financial organization,

YES

do you want this to continue?

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2008?

If you attain full retirement age (FRA) in 2008, your exempt amount is $36,120 ($3,010 a

month) for the months before the month you attain FRA. If you attain FRA in 2009 or

2a) MONTH AND YEAR

later, your exempt amount is $13,560 ($1,130).

a. I am working for wages of more than $1,130 a month (under FRA

COMPLETE BOTH

in 2008) or $3,010 a month (if year of FRA attainment) or performing

BOXES

2b) AMOUNT

substantial services in self-employment beginning with the month of_ _ _ _ _ _ _

b. I estimate that my total earnings for this taxable year will be

STOPPING WORK OR LIMITING EARNINGS:

3a) MONTH AND YEAR

a. The last month I worked for wages of more than $1,130 (under FRA in 2008) or

$3,010 (if year of FRA attainment) or performed substantial services in

self-employment was

COMPLETE

3b) AMOUNT

BOTH BOXES

b. I estimate that my total earnings for this taxable year will be

CHANGE IN ESTIMATE:

AMOUNT

I estimate that my total earnings for this taxable year will be

CHECK if you are self-employed, an officer of a corporation, or related to an

officer of a corporation.

DEATH

DIVORCE

ANNULMENT

DATE OF DEATH:

DATE OF DIVORCE:

DATE OF ANNULMENT:

MARRIAGE

DATE OF MARRIAGE (MO., DAY, YR.)

PRINT NEW LAST NAME

(Place of Marriage) (City, County & State)

CHECK if spouse is now receiving Social Security benefits

IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S

SPOUSE'S CLAIM NUMBER

LETTER

NAME

10.

GOING OUTSIDE THE U.S.

NAME OF COUNTRY TO WHICH GOING

DATE GOING

DATE EXPECT TO RETURN

FOR 30 CONSECUTIVE

DAYS OR LONGER

11.

CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR

DATE LEFT YOUR CARE

CARE OR OTHERWISE CHANGED ADDRESS.

12.

CONFINEMENT OR IMPRISONMENT

DATE OF CONFINEMENT

(MONTH, DAY, YEAR)

Confinement in a jail, prison, or other penal institution or correctional facility, based on a

conviction. Confinement in an institution by court order as a result of certain criminal cases.

13.

GOVERNMENT PENSION OR ANNUITY

13a) MONTH AND YEAR

a. I began receiving a government pension or annuity from the Federal

government or any State or any political subdivision or my present

13b) MONTHLY AMOUNT

payments have changed beginning with the month of

COMPLETE BOTH BOXES

b. The amount of government pension or annuity I receive is or has been changed to

14.

RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT

BEGINNING DATE ENDING DATE

AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR

MONTH/YEAR

ANNUITY, STOPPED.

SIGNATURE OF PERSON MAKING THIS REPORT

DATE SIGNED

NAME OF COUNTRY, IF ANY, IN

NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE

IS THIS A NEW ADDRESS?

WHICH YOU LIVE

Yes

CITY, STATE

ZIP CODE

TELEPHONE NUMBER WHERE WE CAN REACH YOU

(INCLUDE AREA CODE)

Form SSA-1425 (04-2008) EF (08-2008) Destroy Prior Editions

Reporting Changes That Affect Your Social Security Payment

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