SSA-2519

Child Relationship Statement

Download and Print the SSA-2519

PRINT WAGE EARNER'S NAME

WAGE EARNER'S SOCIAL SECURITY NUMBER

List below all children of the wage earner (hereafter referred to as the worker) for whom you are requesting benefits.

NAME OF CHILD OR CHILDREN

A child of the worker may be entitled to benefits if:

(1) the worker was decreed by a court to be the child's parent; or

(2) the worker was ordered by a court to contribute to the child's support because the child is his or her son or daughter; or

(3) the worker acknowledged in writing that the child is his or her son or daughter; or

(4) the child is living with or receiving contributions from his or her parent at certain times. The questions below are designed to help Social Security determine if the child can meet these requirements. Please use item 4 on the reverse of this form for any comments you wish to make.

1. Was the worker ever decreed by a court to be the child's parent?  YES - NO

if "YES," please submit a copy of that decree or give us the name of the court and the date of the decree. (If "YES," omit items 2,3, and 4.)
And much more...