SSA-781

Certificate Of Responsibility For Welfare And Care Of Child Not In Applicant's Custody

Download and Print the SSA-781

All items on this form requiring an answer must be answered or marked "Unknown."
PRIVACY ACT STATEMENT: Collection and Use of Personal Information Sections 202(b) and (g) [42 U.S.C. 402(b) and (g)] of the Social Security Act authorize us to collect this information. We will use the information you provide to confirm past and continuing entitlement to benefits and to determine whether such benefits are subject to suspension or termination. The information you provide on this form is voluntary. However, failure to provide all or part of the requested information is cause for us to suspend your benefit payments. We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following: 1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage; 2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office, General Services Administration, National Archives Records Administration, and the Department of Veterans Affairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and 4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded and administered benefit programs for repayment of payments or delinquent debts under these programs. The law allows us to do this even if you do not agree to it. A complete list of routine uses for this information is available in our System of Records Notice entitled, Claims Folder System, 60-0089. This notice, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at any Social Security office.
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 10 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 on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
I make this statement in support of my application for insurance benefits payable under Title II of the Social Security Act, as amended.

1. Give the following information about all unmarried children of the above wage earner or self-employed person who are not living with you and are: (a) under age 16, or (b) age 16 or over, with a disability that began before age 22. Include natural children, adopted children, stepchildren, and dependent grandchildren or step-grandchildren.

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