SSA-3881

Questionnaire For Children Claiming SSI Benefits

Download and Print the SSA-3881

Request may not be processed if the form is incomplete or illegible.

Please print, type, or write clearly and answer all items to the best of your ability. If you need help completing any part of this form, we will help you. If you are filing on behalf of someone else, enter his or her name and social security number in the space provided and answer all questions. If you do not know the answer, enter "unknown." If the question does not apply, enter "N/A." If you need more space to answer any of the questions, please use "REMARKS" and enter the number of the question next to your answer.
Child's Full Name
Social Security Number
- -
Date (month, day, year)
Informant's Name
Relationship to Child
Daytime Telephone Number (including Area Code)
1. Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare and/or after school program? If so, please specify. If more than one of the above, use the "REMARKS" section.
Name
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
Dates Attended
2. a. Is (was) the child in school?

Yes - No
If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here. (If more than one, use the "REMARKS" section.)
Name

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

Dates Attended

Grade Level Completed

Last Teacher's Name

Page 2
2.b. Is the child in a special education program?
Yes - No
Don't Know

c. Does the school make any special accommodations for the child; e.g., adaptive furniture, wheelchair ramps, extra assistance or attention?

Yes - No
Don't Know
If "yes" in 2.b. or 2.c., indicate type of program and/or accommodations:
Specify number of hours per week the child is in special education program:
d. Do you have a copy of the child's individual education plan (IEP), the report in which the teacher outlines the child's problems and lists the plans for correcting them?

And much more...