Form SSA-1425 REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYME

Form Approved
OMB No. 0960-0073

SOCIAL SECURITY ADMINISTRATION

REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT
USE THIS FORM WHEN THERE IS A CHANGE TO BE REPORTED. ONLY COMPLETE THE ITEM(S) THAT HAVE CHANGED.
PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
You should include the letter or letter and number A, B, B2 C, C1,
D, E, F, or H.
Your report cannot be processed without the correct claim number.

LETTER

DO YOU GET SSI BENEFITS? (Check one)
1.

CHANGE OF ADDRESS (Print new address at bottom)
If Social Security sends your payments to your financial organization,
do you want this to continue?

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2008?
If you attain full retirement age (FRA) in 2008, your exempt amount is $36,120 ($3,010 a
month) for the months before the month you attain FRA. If you attain FRA in 2009 or
later, your exempt amount is $13,560 ($1,130).
a. I am working for wages of more than $1,130 a month (under FRA
COMPLETE BOTH
BOXES
in 2008) or $3,010 a month (if year of FRA attainment) or performing
substantial services in self-employment beginning with the month of_ _ _ _ _ _ _
b. I estimate that my total earnings for this taxable year will be
3.
STOPPING WORK OR LIMITING EARNINGS:
a. The last month I worked for wages of more than $1,130 (under FRA in 2008) or
$3,010 (if year of FRA attainment) or performed substantial services in
COMPLETE
self-employment was

YES

NO

YES

NO

2.

2a) MONTH AND YEAR

2b) AMOUNT

$
3a) MONTH AND YEAR

3b) AMOUNT

BOTH BOXES

$

b. I estimate that my total earnings for this taxable year will be
4.

CHANGE IN ESTIMATE:
I estimate that my total earnings for this taxable year will be

5.

CHECK if you are self-employed, an officer of a corporation, or related to an
officer of a corporation.

6.

DEATH

7.

DATE OF DEATH:

9.

AMOUNT

$

DIVORCE

8.

DATE OF DIVORCE:

MARRIAGE (Place of Marriage) (City, County & State)

ANNULMENT
DATE OF ANNULMENT:

DATE OF MARRIAGE (MO., DAY, YR.) PRINT NEW LAST NAME

CHECK if spouse is now receiving Social Security benefits
IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S
NAME

SPOUSE'S CLAIM NUMBER

10.

GOING OUTSIDE THE U.S.
FOR 30 CONSECUTIVE
DAYS OR LONGER

DATE GOING

11.

CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR
CARE OR OTHERWISE CHANGED ADDRESS.

DATE LEFT YOUR CARE

12.

CONFINEMENT OR IMPRISONMENT
Confinement in a jail, prison, or other penal institution or correctional facility, based on a
conviction. Confinement in an institution by court order as a result of certain criminal cases.

DATE OF CONFINEMENT
(MONTH, DAY, YEAR)

13.

GOVERNMENT PENSION OR ANNUITY

13a) MONTH AND YEAR

NAME OF COUNTRY TO WHICH GOING

DATE EXPECT TO RETURN

a. I began receiving a government pension or annuity from the Federal
government or any State or any political subdivision or my present
payments have changed beginning with the month of

13b) MONTHLY AMOUNT

$

COMPLETE BOTH BOXES

b. The amount of government pension or annuity I receive is or has been changed to
14.

BEGINNING DATE ENDING DATE

RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT
AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR
ANNUITY, STOPPED.

MONTH/YEAR

SIGNATURE OF PERSON MAKING THIS REPORT

MONTH/YEAR

DATE SIGNED

NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE

IS THIS A NEW ADDRESS?

Yes
CITY, STATE

LETTER

ZIP CODE

Form SSA-1425 (04-2008) EF (08-2008) Destroy Prior Editions

No

NAME OF COUNTRY, IF ANY, IN
WHICH YOU LIVE

TELEPHONE NUMBER WHERE WE CAN REACH YOU
(INCLUDE AREA CODE)

HOW TO REPORT

CONFIDENTIAL INFORMATION

There are three ways to report:

The information you give on this form will be used to
determine if you are still eligible for Social Security
benefits and to make sure the amount of your benefit is
correct. Under certain limited conditions authorized by
law or regulation, Social Security may disclose this
information to another individual or government agency
in order to:

1. PHONE Social Security and explain the change.
Telephone Number (

(Area Code)

)

2. VISIT Social Security
3. MAIL this form to Social Security. Make sure you fill in:
·• NAME of person(s) the report is about

• The correct CLAIM NUMBER under which the
benefits are payable

• Whether the person(s) also receives SSI or Black
Lung benefits.
• 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 law Sections 202, 203, and 205 of the Social Security Act,
as amended (42 United States Code 402, 403, and 405.)
required you to promptly report certain changes in your
circumstances which could affect your continuing eligibility to
benefits or your benefit amount. The kinds of changes you
must report to Social Security are listed on the reverse side of
this form. The booklet, "Your Social Security Rights and
Responsibilities, "tells more about reporting changes. If you
do not have this booklet or if you want help in making a
report, get in touch with any Social Security office. The people
there will be glad to help you.

FAILURE TO REPORT
If you do not report changes in your circumstances, 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.
If you hide or do not report a change with the intent to
fraudulently get more benefits or benefits not due you,
you may be fined, imprisoned, or both per Section 208 of
the Social Security Act.

• assist Social Security in establishing the right of an
individual to Social Security benefits and/or the
amount of the benefits;
• facilitate statistical research and audit activities
necessary to assure the integrity and improvement of
the programs administered by Social Security; and
• comply with Federal laws requiring the exchange of
information between Social Security and another
agency (such as the General Accounting Office and
the Veterans Administration).
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, and 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 Security offices. If you want to learn
more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT
Paperwork Reduction Act Statement - This information
collection meets the clearance 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.

See below for
revised Paperwork
Reduction Act
statement.

Use this form only when there is a change to report to Social Security
Form SSA-1425 (04-2008) EF (08-2008)

Reporting Changes That Affect Your Social Security Payment – Form SSA-1425
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 203, and 205 of the Social Security Act, as amended (42 U.S.C. 402,
403, and 405) authorizes us to collect this information. We will us the information
you provide to assist us in determining your continuing eligibility to benefits or your
benefit amount. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on your claim or could result in the loss of
benefits.
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.
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 your local Social
Security office.

SSA will insert the following revised PRA Statement 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. 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 1800-325-0778). 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.