SSA-783

Statement Regarding Contributions

Download and Print the SSA-783

ACT NOTICE: This notice is given pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). The information requested on this form is sought pursuant to the authority granted in Sections 202(d) and (h) of the Social Security Act. The information provided will be used to confirm entitlement to such benefits. Other uses which may be made of the information are summarized below. While completion of this form is voluntary, failure to provide all or any part of the requested information may be cause for denial of benefits. The information you furnish on this form may be disclosed by Social Security to another person or to another governmental agency as follows for the following purposes: (1) to assist Social Security in establishing the right of an individual to Social Security benefits; (2) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs; and (3) to comply with Federal laws requiring the exchange of information between Social Security and another agency. Computer Matching: We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanation about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact 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 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. To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
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.
FROM
TO
NAME AND ADDRESS OF CONTRIBUTORS
RELATIONSHIP TO CLAIMANT
CONTRIBUTIONS
BEGAN - MO. - YR. -

ENDED - MO. - YR.
HOW OFTEN MADE (Weekly, monthly or occasionally)
AVERAGE AMOUNT OF CONTRIBUTION
$
$
$
(b) Was there any break in contributions by any contributor within the period? YES - NO
If "Yes," give name of contributor, months in which no contributions were made, and reason:
(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 he 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
$
$
(e) Give name and address of person or agency to which payments were made for claimant's support:
(

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