SSA-783: Social Security Statement Regarding Contributions

Print the name of the wage earner or self-employed person and enter the Social Security number.

Print your full name (first name, middle initial, last name) and your relationship to the claimant.

Print the name of the claimant and the relationship to the wage earner or self-employed person.

In 1(a), give the information for the period indicated about each person or agency who contributed to the claimant's support.

Under Name and Address of Contributors, enter each contributor and the relationship to the claimant.

Under Contributions, for Began and Ended, enter MO. and YR.

Under How Often Made, enter weekly, monthly or occasionally.

Under Average Amount of Contribution, enter the amount.

Mark Yes or No for any break in contributions by any contributor within the period. If "Yes," give name of contributor, months in which no contributions were made, and reason.

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 contributions stopped.

If other than cash was contributed, such as clothing, board or room, give the name of contributor, items contributed and approximate value for items supplied during the period in 1(a).

Give name and address of person or agency to which payments were made for claimant's support.

Did the claimant have wages or income of his or her own? Mark Yes or No.

If "Yes," enter how much per month and specify in which months.

Mark Yes if the claimant is a child who lived with more than one parent (including stepparents) and answer (b), (c) and (d). If "No," go on to item 4.

If both parents with whom child lived contributed to child's support, did they use their monies as one household fund? Mark Yes or No. If "Yes," enter how much each contributed to the fund.

If their monies were not combined, write what understanding they had as to how much each would contribute to the child's support.

Enter the monthly income of each, for Mother and Father.

Write how you learned of the facts you gave in questions 1, 2, and 3.

Sign on the signature line in ink and enter your first name, middle initial, last name, and the date (MM/DD/YYYY).

Enter your telephone number (including area code), your mailing address (number and street, Apt No., P.O. Box, or Rural Route), city and state, ZIP code, and the name of the county (if any) in which you now live.

Witnesses are required only if the statement has been signed by mark (X). If signed by mark (X), two witnesses to the signing who know the person making the statement must sign, giving their full addresses.

Each witness enters a signature and an address (number and street, city, state, and ZIP code).

You can find your local Social Security office through SSA's website at www.socialsecurity.gov.

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.

Signing declares under penalty of perjury that you 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 your knowledge.