Form SSA-783 PDF Details

The SSA-783 form is a critical document utilized by the Social Security Administration to assess and process claims for insurance benefits under Title II of the Social Security Act. This thorough form requires an in-depth account of the contributions made to the claimant's support by various individuals or agencies, capturing a wide span of information from the amount and frequency of contributions to the specifics of any non-monetary support provided, such as clothing or lodging. In addition, it delves into the claimant's own income and the living arrangements of a child claimant with more than one parent, aiming to piece together a comprehensive picture of the claimant's financial support system. The form's exhaustive nature and the emphasis on accuracy and truthfulness underscore the importance of providing detailed and honest information, as the data collected serves as a foundational element in determining eligibility for benefits. With implications for both the immediate and extended family's financial wellbeing, the SSA-783 form stands as a vital link in the chain of social security benefits application and administration, embodying the legal and procedural safeguards that govern these processes.

QuestionAnswer
Form Name Form SSA-783
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names ssa 783, ssa statement regarding, ssa regarding form, ssa 783 form

Form Preview Example

Form SSA-783 (06-2019) UF

Page 1 of 3

Discontinue Prior Editions

 

Social Security Administration

OMB No. 0960-0020

 

 

STATEMENT REGARDING CONTRIBUTIONS

All items on this form requiring an answer must be answered or marked "Unknown."

PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

ENTER SOCIAL SECURITY NUMBER

 

 

I understand that information given by me will be used in connection with an application for insurance benefits payable under the provisions of Title II of the Social Security Act, as amended, on the record of the wage earner or self-employed person named above.

PRINT NAME YOUR FULL NAME (FIRST NAME, MIDDLE INITIAL, LAST NAME)

RELATIONSHIP TO CLAIMANT

 

 

PRINT NAME OF CLAIMANT

RELATIONSHIP TO WAGE EARNER

OR SELF-EMPLOYED PERSON

 

 

 

1.

(a)Give the following information (for the period indicated below) about each person or agency who contributed to the claimant's support.

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTRIBUTIONS

HOW OFTEN

AVERAGE

NAME AND ADDRESS OF

RELATIONSHIP TO

 

 

 

 

MADE

BEGAN

ENDED

AMOUNT OF

CONTRIBUTORS

CLAIMANT

(Weekly, monthly

 

 

 

 

CONTRIBUTION

 

 

 

MO.

YR.

MO.

YR.

or occasionally)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

b) Was there any break in contributions by any contributor within the period?

Yes

No

If "Yes," give name of contributor, months in which no contributions were made, and reason:

 

 

(c)If any contributions ended before the wage earner's or self-employed person's death or, if living, before application was filed, give name of contributor and why he stopped:

(d)If other than cash was contributed, such as clothing, board or room, give the following information regarding items supplied during the period in 1(a).

NAME OF CONTRIBUTOR

ITEMS CONTRIBUTED

APPROXIMATE VALUE

 

 

 

 

 

 

(e) Give name and address of person or agency to which payments were made for claimant's support:

Form SSA-783 (06-2019) UF

 

 

Page 2 of 3

 

 

 

 

 

 

2. Did the claimant have wages or income of his or her own?

Yes

No If "Yes," how much per month? $

 

 

 

 

 

 

 

IN WHICH MONTHS (Specify)

 

 

 

 

3.(a) Is claimant a child who lived with more than one parent (Including Stepparents)?

Yes "If "Yes," answer (b), (c) and (d) below

No If "No," go on to item 4

 

 

 

 

 

 

(b) If both parents with whom child lived contributed to child's support, did they use their

Yes

No

monies as one household fund?

 

 

 

 

 

 

 

 

 

If "Yes," how much did each contribute the fund?

 

Mother/Father

 

Mother/Father

$

 

$

 

 

 

 

 

 

 

 

 

(c)If their monies were not combined, what understanding did they have as to how much each would contribute to the child's support?

 

(d) What was the monthly income of each?

Mother/Father

Mother/Father

 

$

$

 

 

 

 

 

 

4. How did you learn of the facts you gave in questions 1,2, and 3?

 

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 PERSON MAKING STATEMENT

SIGNATURE (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)

TELEPHONE NUMBER (Including Area Code)

MAILING ADDRESS (Number and street, Apt No., 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 statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person making the statement 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)

Form SSA-783 (06-2019) UF

Page 3 of 3

 

 

Privacy Act Statement

Collection and Use of Personal Information

Sections 202(d), 202(h), and 216(e) 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 us from making an accurate and timely decision in determining the child applicant’s eligibility for benefits.

We will use the information to make a determination for eligibility of benefits. We may also share your information for the following purposes, called routine uses:

1.To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to the individual’s capability to manage affairs or eligibility for or entitlement to benefits under the Social Security program when the data is needed to establish the validity of evidence or to verify the accuracy of information presented by the individual, and it concerns the individual’s eligibility for benefits under the Social Security program; and

2.To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash income maintenance or health maintenance programs (including programs under the Act).

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, 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 Systems. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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 control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

How to Edit Form SSA-783 Online for Free

Whenever you intend to fill out ssa 783, you won't need to install any kind of software - just try our online PDF editor. To make our editor better and more convenient to work with, we continuously design new features, with our users' suggestions in mind. By taking a couple of basic steps, you can start your PDF journey:

Step 1: Click on the "Get Form" button in the top part of this page to open our PDF tool.

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When it comes to blank fields of this specific document, this is what you need to know:

1. First of all, once filling out the ssa 783, start with the page that features the following fields:

ssa regarding online writing process detailed (stage 1)

2. Just after filling out the last section, go on to the subsequent part and fill out the essential particulars in these fields - b Was there any break in, Yes, c If any contributions ended, d If other than cash was, NAME OF CONTRIBUTOR, ITEMS CONTRIBUTED, and APPROXIMATE VALUE.

ITEMS CONTRIBUTED, Yes, and d If other than cash was in ssa regarding online

It's very easy to make a mistake when filling out your ITEMS CONTRIBUTED, so make sure that you reread it prior to deciding to submit it.

3. Completing e Give name and address of person is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part # 3 of filling out ssa regarding online

4. The subsequent paragraph requires your involvement in the following parts: Form SSA UF Did the claimant, IN WHICH MONTHS Specify, Yes, If Yes how much per month, Page of, a Is claimant a child who lived, Yes If Yes answer b c and d below, No If No go on to item, b If both parents with whom child, Yes, If Yes how much did each, MotherFather, MotherFather, c If their monies were not, and d What was the monthly income of. Remember to enter all of the requested details to move further.

Tips on how to prepare ssa regarding online stage 4

5. The very last notch to finalize this PDF form is crucial. You need to fill out the required form fields, consisting of How did you learn of the facts you, I declare under penalty of perjury, SIGNATURE First name middle, DATE Month day year, SIGNATURE OF PERSON MAKING, and TELEPHONE NUMBER Including Area, prior to using the file. Otherwise, it could give you a flawed and potentially incorrect document!

Step # 5 in filling in ssa regarding online

Step 3: Check all the details you have typed into the form fields and then press the "Done" button. Join FormsPal right now and easily get access to ssa 783, ready for downloading. All changes made by you are kept , making it possible to change the document at a later stage as required. FormsPal is devoted to the personal privacy of all our users; we make certain that all personal information processed by our system remains protected.

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