Form SSA-783 Statement Regarding Contributions

Form SSA-783 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0020

STATEMENT REGARDING CONTRIBUTIONS
All items on this form requiring an answer must be answered or marked "Unknown."
If you need more space for explaining any answers to the questions, attach a separate sheet.
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 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.
PERIOD
FROM

Unknown

PERIOD
TO

Unknown

CONTRIBUTIONS
NAME AND ADDRESS OF
CONTRIBUTORS

RELATIONSHIP TO
CLAIMANT

BEGAN
MO.

YR.

ENDED
MO.

YR.

HOW OFTEN
AVERAGE
MADE
AMOUNT OF
(Weekly, monthly
CONTRIBUTION
or occasionally)
$

Unknown

Unknown

Unknown

Unknown
$

Unknown

Unknown

Unknown

Unknown
$

Unknown

Unknown

Unknown

(b) Was there 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:

Yes

Unknown
No

(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 contributions 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

Unknown

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

Form SSA-783 (XX-XXXX) UF
2. Did the claimant have wages or income of his or her own?

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Yes

If "Yes," how much per month? $

No

Unknown

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
monies as one household fund?

Yes

Mother/Father

No
Mother/Father

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

$
Unknown

Unknown

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

Mother/Father

Mother/Father
(d) What was the monthly income of each?

$

$
Unknown

Unknown

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 (MM/DD/YYYY)
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 (XX-XXXX) UF

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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 you provide to make a determination for eligibility of benefits. We may also
share the information for the following purposes, called routine uses:
• To third party contacts (e.g., employers and private pension plans) in situations where the party to be
contacted has, or is expected to have, information relating to the individual's capability to manage his or
her benefits or payments, or his or her eligibility for or entitlement to benefits or eligibility for payments,
under the Social Security program; and
• To Federal, State, or local agencies (or agents on their behalf) for income maintenance or health
maintenance programs including programs under the Social Security 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 Notices (SORNs)
60-0089, Claims Folders Systems, as published in the Federal Register (FR) on October 31, 2019, at 84
FR 58422; 60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR
1826; and 60-0320, Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020, at 85
FR 34477. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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. You can find your local Social Security office through SSA's
website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may
send comments regarding this burden estimate or any other aspect of this collection, including suggestions for
reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate or other aspects of this collection to this address, not the completed form.