Child Relationship Statement (Current Version)

TOE 120

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0116

CHILD RELATIONSHIP STATEMENT

Privacy Act/Paperwork Act Notice: The information requested by this form is authorized by Section 216(h) of the Social Security Act (42 U.S.C. 416(h)). Your
response to the following questions will be used to help establish the child's relationship to the worker on whose record a claim has been filed. Completion of this
form is voluntary. Failure to provide all or any part of the requested information will hinder the development of the child's claim and may result in denial of the
claim. The information you furnish may be disclosed by Social Security to another person or to another governmental agency 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 (e.g., the Bureau of the Census): and (3) to comply with Federal laws requiring the exchange of
information between Social Security and another agency (e.g., the General Accounting Office).
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.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Securitey 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 THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. To find the nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-6401.
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?
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.)
2. Was the worker ever ordered by a court to contribute to the child's support because
the child was his or her son or daughter?
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 3 and 4.)

YES

NO

YES

NO

If you answer "YES" to any of the questions under Item 3, submit the document if available or complete Item 4 on the reverse side of this form. If you are unsure of an answer explain in Item 4.
IN ALL CASES COMPLETE NAME AND ADDRESS BLOCK ON THE OTHER SIDE OF THIS FORM.
3. (a) Did the worker ever file an application with or make a statement to the Veterans
Administration or welfare office or to any government agency in which he/she
stated the child was his/hers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b) Has the worker written any letters to anyone that you know of in which he/she may have
referred to the child as a son or daughter or referred to himself/herself as the child's parent . .
(c) Did the worker ever list the child in a family tree or other family record? . . . . . . . . . . . . . . . . .
(d) Did the worker ever list the child as a dependent on a tax return? . . . . . . . . . . . . . . . . . . . . . .
(e) Did the worker ever take out any insurance policies on the child or make the child a
beneficiary of his/her own insurance policy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(f) Did the worker ever make a will listing the child beneficiary . . . . . . . . . . . . . . . . . . . . . . . . . .
(g) Did the worker ever make an allotment for the child while he/she was in military service? . . . . .
(h) Did the worker ever list the child on any applications for employment? . . . . . . . . . . . . . . . .
(i) Did the worker ever register the child in school or place of worship or sign a report
card as the child's parent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(j) Did the worker ever take the child to a doctor's or dentist's office or to a hospital and
list himself/herself as parent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(k) Did the worker accept responsibility for or pay the child's hospital expenses at birth or
did he/she give the information for the child's birth certificate? . . . . . . . . . . . . . . . . . . . . . .
(l) Do you know of any other written evidence of any kind which would show that the child
is the son or daughter of the worker? (The information need not have been supplied by
the worker.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(m) Is there anyone to whom the worker admitted orally that he/she was the parent of the
child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(n) Is the worker making regular and substantial contributions to the child's support or
was the worker making such contributions at that time the worker died? . . . . . . . . . . . . . . . .
Form SSA-2519 (04-2002) EF (08-2004) Use prior editions

YES

NO

YES
YES
YES

NO
NO
NO

YES
YES
YES
YES

NO
NO
NO
NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

OVER

4. If you answered "YES," to any of the questions in Item 3 identify the question (e.g., "3(a)") and supply detailed information
below. For example: You should provide the names and addresses of government agencies, doctors, hospitals, schools, etc.
where appropriate. The approximate date of the event and the surrounding circumstances should be indicated. The
information should be in sufficient detail to enable us to locate the document or evidence remembering the final responsibility
for supplying this evidence is yours. Where more than one child is filing for benefits identify below the child to whom the
evidence pertains.

NAME OF PERSON COMPLETING FORM

DATE

ADDRESS (NUMBER AND STREET OR P.O. BOX, OR RURAL ROUTE)

TELEPHONE NO. & AREA CODE

CITY AND STATE

ZIP CODE

5. FOR DISTRICT OFFICE USE ONLY
A. Explain all development taken as a result of "YES" answers. Questions 3(l) and 3(m) are designed to uncover sources of
"Other Evidence" of parentage where the child was living with or receiving contributions from the worker at the
appropriate times, or to uncover other sources of an acknowledgement in writing by the worker.

B. Outline all other pertinent relationship development made on this claim. (This suffices for the required RC.) When
considering the status of an out-of-wedlock child, you may not disallow the child until you consider applicable State
intestacy law.
State of Domicile:

Form SSA-2519 (04-2002) EF (08-2004)