Form SSA-612 Report of New Information in isability Cases

Form Approved OMS

SOCIAL SECURITY ADMINISTRATION

No. 0960·0071

REPORT OF NEW INFORMATION IN DISABILITY CASES

USE THIS FORM ONLY WHEN THERE IS A CHANGE TO BE REPORTED

PRINT NAME OF DISABLED PERSON OR PERSONS ABOUT WHOM REPORT IS MADE

~-------------------------------------------------------­
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID.

It is a nine digit number (000-00-00001 followed by a letter only or by a letter and a number (A, B, B2,C, c" D, E, F, or H.I

Your report cannot be processed without the correct claim number.

LEITER

~-=~~~==~==~==~==~==~~==~------­
.... 00 YOU ALSO RECEIVE SSI OR BLACK LUNG BENEFITS? (Check one)

1.

0

2.

0

3.

0

CHANGE OF ADDRESS (Print new address at bottoml
If the Social Security Administration is sending your payments to
your financial organization, do you wish this to continue?

DYES

[] NO

0

0

YES

NO

DISABLED PERSON'S CONDITION HAS IMPROVED OR PHYSICIAN HAS ADVISED THAT DISABLED PERSON CAN
RETURN TO WORK.
DISABLED PERSON RETURNED TO WORK OR STOPPED WORK
MONTH, DAY, AND YEAR
(al Disabled person began working on: - - - - - - - - - - - - - - - - ­
'--_ _ _ _ _ _ _ _ _ _ _ __
(b) Place and address of employment or self employment:

(c)

Disabled person's total monthly earnings for each month are: !If an employee. enter each month's gross earnings. If self-employed. enter each month's net
earnings and the number of houls worked in each month.l

Month:

Amount:

$

$

$

$

$

$

$

Hours:

MONTH. DAY, AND YEAR

(d) Disabled person is still working

0

YES

0

NO

(If NO is checked, answer Me") (e)

4.

0

DISABLED PERSON LEFT CUSTODY OF REPRESENTATIVE PAYEE ON
Disabled person's present address:

5.

0

DISABLED PERSON DIED ON

6.

0

DISABLED PERSON GOING OUTSIDE THE U.S.

MONTH, DAY, AND YEAR
•

DATE GOING

NAME OF COUNTRY:

DATE EXPECTED TO RETURN
DATE OF MARRIAGE

7.

0

DISABLED PERSON MARRIED O N - - - - - - - - - - - - - - - - - t

8.

0

DISABLED PERSON IS RECEIVING WORKERS' COMPENSATION (INCLUDING BLACK LUNG BENEFITS) OR ANOTHER
PUBUC DISABIUTY BENEFIT OR THE AMOUNT OF PRESENT PAYMENT HAS CHANGED.

la) Lump sum payment of

I

Ib) Date of latest award

t

Ie) Claim Number

•

Idl Change in periodic payment amount:

9.

•

$

MONTH, DAY, AND YEAR

/NUMBER

I~ROM

TO
$

o Disabled person begins to receive a pension or annuity based on employment after
1956 not covered by Social Security, or cessation of such pension or annuity.

10.0 Confinement as a result of a criminal offense in a jail, prison, or other penal
institution, correctional facility, or certain mental health institutions.

Beginning Date
(MonthNear)

Ending Date
IMonthNear)

DATE OF CONFINEMENT
(MONTH. DAY, YEAR)

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

ZIP CODE
TELEPHONE NUMBER (If any)

Form SSA-612 (6-2000) EF (08-2006)

ENTER NAME OF COUNTY. IF ANY. IN WHICH YOU LIVE
OVER

HOW TO REPORT

There are three ways to report:

1. Phone Social Security and explain the change.
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 disabled person 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.
NOTE: REMEMBER TO TELL US WHEN YOU MOVE,
EVEN IF YOUR MAILING ADDRESS FOR CHECKS
HAS NOT CHANGED.
IMPORTANT INFORMATION
PRIVACY ACT NOTICE: This report is authorized by
20 CFR 404.1588. See Revised Privacy Act

Statement
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 gov- ernment. The law allows us to do
this even if you do not agree to it.
Explanations about these and other reasons why
infor- mation you provide us may be used or given
out are available in Social Security Offices. If you
want to learn more about this, contact us at
1-800-772-1213 or at any Social Security Office.
This
Paperwork Reduction Act Statement
information collection meets the requirements of 44
U.S.C. § 3507, as amended by Section 2 of the
Paperwork Reduction Act Qf.... 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 5
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..&00-772-1213.
Send only comments on our
time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401.

All requests for Social Security cards and other
claims-related information should be sent to your
local Social Security office, whose address is listed
under Social Security Administration in the U.S.
Government section of your telephone directory.
WHAT TO REPORT
The kinds of events that you must report to Social
Security are listed on the other side of this form.
The booklet, "What You Need To Know When You
Get Disability Benefits,' , tells more about these
reporting events. If you do not have this booklet or
if you want help in making a report, get in touch
with any Social Security Office and the people
there will be glad to help you.
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 you.
Also if you conceal or fail to disclose a reporting
event with an intent to fraudulently obtain benefits
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.
INFORMATION CONFIDEN1-IAL
The information furnished on this form will be used
to determine if you are still eligible for Social
Security disability benefits or if they should be
changed. This information may be disclosed by
Social Security to another person or to another
agency for the following purposes:
• to assist Social Security in establishing
the right of an individual to Social
Security bene- fits and/or the amount of
the benefits;
• to facilitate statistical research and audit
activities necessary to assure the integrity
and improvement of the programs
administered by Social Security; and
• to comply with Federal laws requiring the
exchange of information between Social
Security and another agency, (such as the
State Vocational Rehabilitation Agencies
for rehabilitation services).
NOTE: USE THIS FORM ONLY IF YOU HAVE A
CHANGE TO REPORT

See Revised Paperwork Reduction Act Statement
Use this form only when there is a change to report to Social Security.
Form SSA-612 (6-2000) EF (08-2006)

G:O'

u.s. GOVERNMENT PRINTING OFFICE: 2006-330-080160003

The following revised Privacy Act Statement will be inserted into the form at its next
scheduled reprinting:

Privacy Act Statement
Collection and Use of Personal Information
Section 404.1588 of the Social Security Act, as amended, authorizes us to collect this
information. The information is needed to make a determination regarding the correct
amount of benefits due to you. Your response is voluntary. However, failure to provide
all or part of the requested information could prevent an accurate and timely decision on
your request.
We rarely use the information provided on this form for any other 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 and Department of
Veteran 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 and for repayment of payments or delinquent debts under these programs.
A complete list of routines uses for this information is available in Systems of Records
Notice 60-0089. This notice, as well as several other applicable Systems of Records
Notices pertinent to this form, and information regarding our programs and systems, is
available on-line at www.socialsecurity.gov or at your local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 5
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 (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.