Form Ssa 1372 Bk – Fill Out and Use This PDF

Form SSA 1372 BK is a document issued by the United States Social Security Administration. It has multiple usages and requires certain information in order to be completed properly. This form is designed to serve as an authorization within government oversight, such as in instances when individuals wish to make changes or amendments regarding heirs receiving benefits after a relative's death. As such, Form SSA 1372 also serves as a record of supporting factual incidents enabling social welfare office investigations, justifications and decisions made. Additionally, this form allows for updates or corrections to individual entitlement awards created originally with other SSA forms. Lastly, Form SSA 1372 BK provides valuable adjudication evidence the Social Security Administration uses to study trends and make administrative regulations.

Form Ssa 1372 Bk PDF Details

The Social Security Administration (SSA) Form 1372 is a certification of authority to act on behalf of the claimant in proceedings before the SSA. The form is used to designate a representative to act on behalf of the claimant in connection with any dealings with the SSA, including requests for hearings and appeals. The form must be completed and filed by anyone filing an application for benefits or wishing to represent someone else in such proceedings. Completed correctly, it can help ensure that your case proceeds as smoothly as possible. Let's take a closer look at what this form is and how it can help you. Form 1372 Bk designates Bruce Kim as your authorized agent with power to represent you before the Social Security Administration (SSA) in all dealings, including but not limited to, requests for hearings and Appeals concerning Title II Disability Benefits under the Social Security Act . This form should be filled out and submitted if you are filing an application for benefit

Question	Answer
Form Name	Form Ssa 1372 Bk
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	ssa notice, ssa statement regarding, ssa 1372 statement, ssa regarding

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Form SSA-1372-BK (12-2017) UF	Page 1 of 7
Discontinue Prior Editions	Page 1 of 7
Social Security Administration	OMB No. 0960-0105

ADVANCE NOTICE OF TERMINATION OF CHILD'S BENEFITS

NAME AND ADDRESS

SOCIAL SECURITY CLAIM NUMBER

NAME OF CHILD BENEFICIARY TO WHOM THIS

STATEMENT APPLIES

DATE CHILD ATTAINS AGE 18

YOUR BENEFITS WILL AUTOMATICALLY STOP AT AGE 18 UNLESS:

●You are a full-time student at an elementary or secondary school (a secondary school is a school at or below the high school level), or

●You qualify for childhood disability benefits.

Your benefits will end with the payment for the month before the month in which you attain age 18. You attain age 18 on the day before your 18th birthday. This is important when your birthday is on the first day of the month. For example, if your 18th birthday is June 1, you attain that age on May 31. If you are neither a full-time student nor disabled in May, benefits would not be payable for May. The last benefit check to which you would be entitled would be the one received in May, which represents your payment for April.

FOR YOU TO RECEIVE STUDENT BENEFITS AFTER AGE 18, YOU MUST:

1.Complete the form, STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE (page 2).

2.Take the form to the school for a school official to certify on page 3 the information you provide on page 2.

3.Leave page 4, NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE, and page 5 with the school official.

4.Bring pages 2 (STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE) and 3 (CERTIFICATION BY SCHOOL OFFICIAL) to a Social Security office or return them in the enclosed envelope (fold page 2 so the address on back shows through window envelope) prior to the age 18 attainment month shown above.

5.For Direct Deposit, bring or mail a voided check or a copy of a bank statement. Your name must be on the account.

TO RECEIVE CHILDHOOD DISABILITY BENEFITS, YOU MUST CONTACT ANY SOCIAL SECURITY OFFICE AND HAVE THE FOLLOWING INFORMATION:

1.A history of the disabling condition, including names and addresses of medical record sources (such as doctors and hospitals) and schools attended. If you have worked, you must also furnish your work history.

2.Your Social Security Number.

Please keep the attached sheet, INFORMATION ABOUT BENEFITS PAST AGE 18 (page 6), for your records. It contains important information about eligibility for student benefits and reporting responsibilities.

	Form SSA-1372-BK (12-2017) UF	Page 2 of 7
	Discontinue Prior Editions	Page 2 of 7
	Social Security Administration	OMB No. 0960-0105
	STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE

	The information requested on this form is sought pursuant to	NAME AND ADDRESS
	authority granted by law (42 U.S.C. 402 and 405). While you
	are not required to respond, your cooperation is needed to
	confirm your past and/or continuing entitlement to
	student benefits.
	SOCIAL SECURITY CLAIM NUMBER
	SOCIAL SECURITY CLAIM NUMBER	(For a change or correction of address, line through the old

		address and insert the new address.)

1.Current School Attendance

(a)Are you now in full-time attendance? Yes No (NOTE: If you are completing this form during a summer break period and you were in full-time attendance prior to the break and will continue school in the fall, you should answer YES to question 1(a). You should show the beginning date of the fall semester for question 1(b). See question 2 for past school attendance information.)

(b) Print School's Name and Address				School Year Began		School Year Will End
				Month, Day, Year		Month, Day, Year

(c) Type of School Program	High School	Home School	GED		Technical	Vocational
	Other (Specify):

(d) Show the number of hours per week you are scheduled to attend						Hours


						Month,Year

(e)Show your EXPECTED graduation date from SECONDARY school (e.g., high school)

(f)What months between now and your expected graduation will you not be in full-

time attendance for the full month? (For example, months of summer vacation)

Last School Year

PAST DATES OF ATTENDANCE

(a) Print School's Name and Address

School Year Began

School Year Ended

Month, Day, Year

(b) Type of School Program

High School

Home School

GED

Technical

Vocational

Other (Specify):

Hours

Are you disabled?

Yes

Are you married?

Month, Day, Year

Yes

(If yes, show the date you were married)

(a) Do you expect to earn more than

in year

Yes

? $

(b) If YES, how much do you expect your total earnings to be in year

Month, Year

in year

Are you being paid by your employer to attend school?

Yes

Do you have a bank account?

Yes

(If yes, attach a voided check or copy of a savings account statement to this form. Student's name must be on the account.)

8.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? Yes No

I understand that SSA will use the earnings reported to SSA by my employer(s) and my self-employment tax return (if applicable) as the report of earnings required by law and adjust benefits under the earnings test. I also understand that it is my responsibility to ensure that the information I give SSA concerning my earnings is correct. I also understand that I must furnish additional information as needed when my benefit adjustment is not correct based on the earnings on my record.

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 or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. I also certify that I have read the detachable information sheet. I authorize my school to disclose to the Social Security Administration any information concerning my status as a student as it pertains to past, current, or future Social Security student benefits.

SIGNATURE OF STUDENT

Signature (First Name, Middle Initial, Last Name (Write in ink))

Mailing Address

Student's Own Social Security Number

Telephone Number (with area code)

Date

Form SSA-1372-BK (12-2017) UF	Page 3 of 7

CERTIFICATION BY SCHOOL OFFICIAL

Name of Student

Social Security Claim Number

Please review the information the student provided on page 2, answer the questions below, annotate the student's expected graduation date on page 4, and sign and date the form in the space provided. You should give pages 2 and 3 to the student to return to the Social Security Administration. Please retain page 4 for reporting if the student's full-time attendance ends, or the student graduates, before the date indicated.

1) All information entered in items 1 and 2 of page 2 is correct according to the school's records.

Yes

2) Is the school's course of study at least 13 weeks in duration?

Yes

3) Please indicate which of the following applies to the school's operating basis.

Yearly

Quarterly/Semester - No Reenrollment Required

Quarterly/Semester - Reenrollment Required

4) I received pages 4 and 5 of this form for reporting changes in the student's attendance.

Yes

5) I annotated page 4 of this form with the student's expected graduation date as reported on page 2 of this form.

Yes

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.


School
Official
Signs		Title
Printed Name
Printed Name
Date	Phone Number (with area code)

The people in your Social Security office will be glad to help you with any questions concerning this form or any other questions you have about Social Security. For more information, please see: www.socialsecurity.gov/schoolofficials/.

Form SSA-1372-BK (12-2017) UF

Page 4 of 7

SCHOOL SHOULD DETACH AND RETAIN THIS FORM

Field Office Name and Address

NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE

NAME OF SOCIAL SECURITY BENEFICIARY

DATE OF BIRTH

SOCIAL SECURITY CLAIM NUMBER

STUDENT'S SOCIAL SECURITY NUMBER

STUDENT'S EXPECTED GRADUATION DATE (FROM PAGE 2)

MONTH, YEAR

INDIVIDUAL IDENTIFIED ABOVE CEASED TO BE A FULL-TIME STUDENT AT THIS SCHOOL ON (MONTH, DAY, YEAR)

REASON:

1. Withdrawal, suspension, or expulsion

2. Changed to part-time status

3. Failed to continue in full-time attendance at start of new term (or new school year) 4. Other (Explain)

NAME AND ADDRESS OF SCHOOL

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.

SIGNATURE (OR FACSIMILE) OF SCHOOL OFFICIAL

PRINTED NAME

TITLE

DATE

IMPORTANT INFORMATION ABOUT THIS FORM

This form contains the name, date of birth, and Social Security claim number of a child beneficiary who tells us that he/she is (or will be when school resumes) a full-time student at your school. One of the conditions a child between 18 and 19 must meet to receive Social Security benefits is that he/she be a full-time student.

Full-Time Attendance

For Social Security purposes, a student in “full-time attendance” is one who is attending an elementary or secondary school and is enrolled in a day or evening non-correspondence course at least 13 weeks in duration. In addition, the student must be scheduled to attend at the rate of at least 20 hours weekly and be carrying a subject load that is considered full-time for day students under the school's standards and practices. If there is any question about whether a student's attendance is full or part-time, please apply your school's usual criteria.

What to Report

Please hold this form until the student is no longer a full-time student at your school (whether this is during the current school year, at the start of the next school year, or any time after that). Then, enter the date he/she stopped being a full- time student, check the appropriate box above and return the completed form to the Social Security office shown above. You should not return the form to report that attendance stopped for a scheduled break (e.g., summer break) unless you do not expect the student to return after the break. You should report if the student stops attending school full-time, or graduates earlier than the expected graduation date shown above. The people in your Social Security office will be glad to help you with any questions concerning this form or any other questions you have about Social Security. For more information, please see: www.socialsecurity.gov/schoolofficials/.

Thanks for your cooperation..

Form SSA-1372-BK (12-2017) UF	Page 5 of 7

Privacy Act Statement

Collection and Use of Personal Information

Sections 202(d) 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 your claim.

We will use the information to verify your school attendance and eligibility for student benefits. We may also share your information for the following purposes, called routine uses:

1.To third party contacts where necessary to establish or verify 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 Social Security 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 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 System. 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 (OMB) control number. We estimate that it will take about 3 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.

Form SSA-1372-BK (12-2017) UF

Page 6 of 7

STUDENT SHOULD DETACH AND KEEP THIS INFORMATION FOR FUTURE REFERENCE

INFORMATION ABOUT BENEFITS PAST AGE 18

If you qualify for Social Security benefits because you are a full-time student, you can start receiving benefits as early as age 18 and usually through the month you graduate from secondary school, or the month before age 19, whichever is earlier. Your benefits will be paid in your own name beginning at age 18, either by direct deposit or by mail. Generally, we consider you to be a full-time student if you are in full-time attendance at a school that provides education at the secondary (grade 12) level or below. Full-time attendance means you are scheduled to attend classes at the rate of 20 hours per week, or at the rate determined by your school to be full-time (if higher).

INFORMATION ABOUT BENEFITS PAST AGE 19

Your benefits may continue past age 19 if you are in actual full-time attendance at a school that provides elementary or secondary education in the month you become age 19. If the school operates on a yearly basis, then payment may be continued after age 19 up through the earlier of (1) the month you complete the course in which you are enrolled full-time or (2) the second month after the month you become age 19. If the school requires re-enrollment on other than a yearly basis, benefits may continue through the month ending the term that is in progress when you become age 19. Note that payments beyond age 19 cannot be made if you become age 19 in a month of nonattendance (for example, you become age 19 in a month when you are on summer vacation).

IMPORTANT RESPONSIBILITIES

YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:

●YOU MARRY

●YOU STOP ATTENDING SCHOOL

●YOU REDUCE YOUR SCHOOL ATTENDANCE BELOW FULL-TIME

●YOU CHANGE SCHOOLS

●YOU ARE PAID BY YOUR EMPLOYER TO ATTEND SCHOOL (at the request of or as a requirement of your employer)

●YOU HAVE AN UNSATISFIED WARRANT FOR YOUR ARREST FOR A CRIME OR AN ATTEMPTED CRIME FOR FLIGHT TO AVOID PROSECUTION OR CONFINEMENT OR ESCAPE FROM CUSTODY

Your benefits may end if any of the above occur. You must report each of these events even if you believe your benefits should not end. We will tell you about how your benefits may be affected.

YOU SHOULD ALSO NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:

●YOU MOVE OR CHANGE YOUR MAILING ADDRESS

●YOUR ESTIMATED EARNINGS FROM WORK CHANGE

When you are awarded Social Security benefits as a student, you will receive a booklet that further covers your responsibilities. It is important for you to read that booklet.

Form SSA-1372-BK (12-2017) UF

Page 7 of 7

Privacy Act Statement

Collection and Use of Personal Information

We will use the information to verify your school attendance and eligibility for student benefits. We may also share your information for the following purposes, called routine uses:

1.To third party contacts where necessary to establish or verify information provided by representative payees or payee applicants; and

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 website at www.socialsecurity.gov/foia/bluebook.

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1. Begin completing the ssa form child with a selection of necessary blanks. Collect all the important information and be sure nothing is left out!

2. Once your current task is complete, take the next step – fill out all of these fields - The information requested on this, NAME AND ADDRESS, For a change or correction of, Current School Attendance a Are, School Year Will End, Yes, School Year Began Month Day Year, Month Day Year, c Type of School Program, High School, Home School, GED, Technical, Vocational, and d Show the number of hours per with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. The following portion will be about Last School Year a Print Schools, School Year Began Month Day Year, School Year Ended Month Day Year, b Type of School Program, High School, Home School, GED, Technical, Vocational, Other Specify, c Show the number of hours per, Are you disabled, Yes, Are you married, and Yes - complete these fields.

Always be really mindful while filling out b Type of School Program and c Show the number of hours per, since this is the part in which a lot of people make some mistakes.

4. The subsequent subsection requires your information in the following areas: Signature First Name Middle, Mailing Address, SIGNATURE OF STUDENT, Students Own Social Security Number, Telephone Number with area code, and Date. Ensure you enter all of the requested details to move further.

5. This form must be finalized by filling out this segment. Below you have an extensive set of form fields that must be filled out with accurate details to allow your document submission to be accomplished: Name of Student, Social Security Claim Number, Please review the information the, All information entered in items, Yes, Is the schools course of study at, Yes, Please indicate which of the, Yearly, QuarterlySemester No Reenrollment, QuarterlySemester Reenrollment, I received pages and of this, Yes, I annotated page of this form, and Yes.

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