Form SSA-1383 Student Reporting Form

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0088

TOE 240

STUDENT REPORTING FORM
Use this form only when there is a change to be reported.
PRINT NAME OF STUDENT
SOCIAL SECURITY CLAIM NUMBER
ON WHICH BENEFITS ARE PAID
It is a nine-digit number (000-00-0000) followed by
letter(s) C or HC. We cannot process your report
without the correct claim number.

LETTER(S)

CHANGE OF ADDRESS (Print new address at bottom of form.)
If the Social Security Administration is sending your payments to your financial
organization, do you want this to continue?

1.

2.

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT - $
year
(specify)

(specify)

for the

YES

NO

MONTH AND YEAR

a. I am working for wages of more than $
a month or performing
substantial services in self-employment beginning with the month of . . . . . . .
AMOUNT
FILL IN BOTH BOXES
b. I estimate that my total earnings for this taxable year will be . . . . . . . . . . . . . . . . $
3.

MARRIAGE OF STUDENT

DATE OF MARRIAGE
(MONTH, DAY, YEAR)

4.

NO LONGER ATTENDING ANY SCHOOL
(Do NOT report this item merely because school year ended if you intend to resume
full-time attendance after a vacation period of not more than 4 full calendar
months.) The last day that I attended school on a full-time basis was

MONTH, DAY, YEAR

5.

REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME

MONTH, DAY, YEAR

The last day that I attended school on a full-time basis was
CHANGED SCHOOLS
I have arranged to transfer schools effective
I am (will be) attending
full-time
part-time
NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records.)

6a.

b.

c. TYPE OF NEW SCHOOL

Post-secondary (College, Junior
College, Trade or Vocational)

Secondary (High school level or
d. STUDENT IDENTIFICATION NUMBER

STUDENT'S SOCIAL SECURITY NUMBER

e. DATE SCHOOL YEAR WILL END

MONTH, YEAR

7a.

MONTH, DAY, YEAR

OTHER

(specify)

MONTH, DAY, YEAR

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on
NAME AND ADDRESS OF EMPLOYER

b.
8.

DATE OF INCARCERATION
(MONTH, DAY, YEAR)

INCARCERATION FOR CONVICTION OF A CRIME
Student is confined in a jail, prison, or other correctional institution
based on a conviction of a crime.
WARRANT ISSUED FOR STUDENT'S ARREST

9.

An unsatisfied warrant was issued for your arrest because you were convicted of or charged with a
crime that carries a penalty of death or confinement of over one year, or you have an unsatisfied
warrant for a Federal or State probation or parole violation.

DATE OF ARREST WARRANT
(MONTH, DAY, YEAR)

SIGNATURE OF PERSON MAKING THIS REPORT
NUMBER AND STREET, APT. NO., P.O. BOX OR RURAL ROUTE
CITY
DATE SIGNED

STATE
AREA CODE & TELEPHONE NO. (IF ANY)

Form SSA-1383 (07-2005) EF (07-2005)

Destroy Prior Editions

ZIP CODE
ENTER NAME OF COUNTY, IF ANY, IN WHICH YOU LIVE

HOW TO REPORT

PRIVACY ACT NOTICE

There are three ways to report:
1. PHONE Social Security and explain the change.
Telephone Number (

)

(Area Code)

2. VISIT any Social Security office.

3. MAIL this form to any Social Security office.
MAKE SURE YOU FILL IN THESE NECESSARY DETAILS
ON THE REVERSE SIDE OF THIS FORM:
•

NAME of student about whom the report is made;

•

The correct CLAIM NUMBER under which the
benefits are payable;

•

WHAT is being reported;

•

DATE it happened;

• Your SIGNATURE and ADDRESS.
If you mail your report, please use this reporting form and
send it to the nearest Social Security office.
NOTE: REMEMBER TO TELL US WHEN YOU MOVE, EVEN
IF YOUR MAILING ADDRESS FOR CHECKS HAS NOT
CHANGED.

WHAT TO REPORT
The kinds of events that you must report to Social Security
are listed on the reverse side of this form. Check any of
the events that apply to you and fill in any other
information requested about the event. If you need more
information to fill out this form, please read "Social
Security: What You Need to Know When You Get
Retirement or Survivors Benefits" and/or "Social Security:
What You Need to Know When You Get Disability
Benefits." If you do not have these publications, or if you
want help in making a report, get in touch with any Social
Security office for help.

The information requested on this form is authorized by the
Social Security Act, Sections 202(d) and 203(f), and Title
20 CFR 404.415, 404.434, 404.352 (b) (2), 404.367,
404.368, and 422.135. The information provided will be
used to determine if you are still eligible for Social Security
benefits. This information may be disclosed by Social
Security to another person or to another agency for the
following purposes: (1) to assist SSA in determining the
right to Social Security benefits for yourself or another
person; (2) to facilitate statistical research and audit
activities necessary to assure the integrity and
improvement of programs administered by SSA; and (3)
to comply with laws and regulations requiring the
exchange of information between SSA and another agency.
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 about you 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
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 6 minutes to read the instructions, gather the facts,
and answer the questions.
SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social
Security at 1-800-772-1213. 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.

FAILURE TO REPORT
If you do not report events as shown on this form, you
may not be paid some or all of the benefits due you, or you
may be overpaid, in which case you will have to pay back
any benefits you received that were not due to you.
Also, if you conceal or fail to disclose a reporting event
with an intent to obtain benefits fraudulently either in a
greater amount than is due or when no payment is
authorized, you may be FINED, IMPRISONED, or both as
provided in section 208 of the Social Security Act.

Use this form ONLY when there is a change to report to Social Security.
Form SSA-1383 (07-2005) EF (07-2005)