Form SSA-760-F4 Certificate of Support

j

TOE 420

SOCIAl SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0001

(Do not write in this space)

CERTIFICATE OF SUPPORT
{There is a time limitation for the filing of this certificate. It should be filed promptly.)

See Revised Privacy
Act Statement

PRIVACY ACT PAPERWORK REDUCTION NOTICE: This form is authorized by sections 202(c), (f) and lhl of the Social
Security Act. as amended (42 U.S.C. 402 (c), (f), and (h) and section 334 of Public Law 95-216. While it is not
mandatory tor you to complete this form, failure to provide the information requested may result in the denial of your
claim for Social Security benefits or to a reduction in your benefit amou11t due to insufficient information. The
information provided will be used to determine whether you meet the support requirements necessary for entitlement
to the benefits for which you are applying or the application of the exception to government pension offset. The
information may be disclosed to another person or to another governmental agency as follows: 1) to enable a third
party or 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 General
Accounting Office and the Veterans Administration); and 3) to facilitate statistical research and audit activities
necessary to assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census

and private concerns under contract to Social Security).
PAPERWORK REDUCTION ACT: 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 are not required to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take you about 10 minutes to read the instructions, gather the necessary facts, and answer the questions.

See Revised Paperwork
Reduction Act

ENTER NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (Herein referred to as the ENTER HIS (HER) SOCIAL SECURITY
"worker"}
NUMBER

PART I - IDENTITY
I intend that this certificate shall be considered as part of my application for insurance benefits which may be
payable to me under the provisions of Title II of the Social Security Act, as amended. I hereby certify that I
was receiving at least one-half my support from the worker at the time specified in Item 8 of this Certificate
and submit the following information as proof of the facts.

1 . Enter your full name (Print or write clearly)

2. Enter your date of birth

3. Enter your Social Security number
(If none, write "None'')

(Month, Day and Year)

I

I

4. (a) Show your relationship to the worker. (Husband, wife, widower, widow, mother, father, stepmother,
adopting father, etc.) (If you indicate that you are the husband, wife, widower, or widow, Skip to item

9.)

5. If the worker has another living parent (other than yourself) enter the following information regarding the
other parent:
FULL NAME

AGE

ADDRESS

RELATIONSHIP TO WORKER (Father,

mother, stepfather, etc.)

6. If vou are a steooarent:
WHEN DID YOU MARRY THE WORKER'S FATHER OR MOTHER? WHERE DID THIS MARRIAGE TAKE PLACE?

7. If vou are an adootina oarent:
WHEN DID YOU ADOPT THE WORKER?

Form SSA-760-F4 (11-1983) EF (6-2001)

WHERE DID THIS ADOPTION TAKE PLACE?

1.

PART II - SUPPORT
YEAR

DAY

MONTH

8.
QUESTIONS 9 THROUGH 19 APPLY TO YOUR INCOME AND
SUPPORT FOR THE 12-MONTH PERIOD ENDING
This form must be filed not later than .
9.

..

DATE

...

Enter the total amount of the worker's income during the 12-month period
shown in item 8.

10. (a) Did you own the dwelling in which you lived during the 12-month period
shown in item 8?

AMOUNT

D

D

Yes

No

(If "Yes," go on to item 11. If "No," enter below the name and relationship of the person who
owned the dwelling in which you lived and complete (b) and if appropriate, (c) and (d).)
RELATIONSHIP TO YOU (If none, write "None.")

NAME OF OWNER

(b) Did you pay either rent or all the costs of maintaining the property (such as
repairs, mortgage, taxes, etc.)?

D

D

Yes

No

Iff "No," answer (c) and (d).)

(If "Yes," skip (c) and (d) and go to item 11 J

(c) List below each person who paid the rent or the costs of maintaining the property, what each paid
for, and how much:
AMOUNT

ITEM PAID FOR

PERSON WHO PAID

$
$
$
$

(d) What was the monthly rental value of the house?

,'

1$

... ·

.

11 . Enter the following about the worker and any other person who lived with you or who contributed to the
support of your household during the 12-month period shown in item 8. Include contributions for
support, payments for room and board, household expenses, clothing, insurance and medical expenses,
gifts, etc.
NAME

RELATIONSHIP
TO YOU

DATES EACH
LIVED WITH

YOU

DATES
EACH CONTRIBUTED

TOTAL AMOUNT
CONTRIBUTED
BY EACH

DATE AND AMOUNT OF
LAST CONTRIBUTION
AMOUNT

DATE

$

$

$

$

$

$

$

$

12. If any of the contributions to you stopped before the end of the period, explain why:
-

-·--~··-·

~-

Form SSA-760-F4 (11-1983) EF (6-2001)

2.

--~.

13. Ia) Did you furnish room and board to anyone who lived with you during the 12 month period shown in
item 8?
No (If "No," go on to item 14)
Yes (If "Yes," complete (b).)

D

D

(b)

PERSON TO WHOM YOU FURNISHED
ROOM AND BOARD

COST OR ESTIMATED COST
OF ROOM AND BOARD (MONTHLY)

DATES FURNISHED

14. Ia) Did you receive any income during the 12-month period shown in item 8 from any of the sources
shown below?

0

Yes (If "Yes," complete (b) below.)

D

No (If "No, "go on to item 15.)

(b)

DATE YOU LAST RECEIVED INCOME
AND AMOUNT

INCOME

SOURCE

AMOUNT

DATE

Wages, salary, commissions, etc. (Show gross amounts before

$

$

Pensions, annuities, insurance (including Social Security
benefits)

$

$

Stocks, bonds, securities, etc.

$

$

deductions for taxes, FICA contributions, insurance, etc.)

15. Did you or any member of the household receive any kind of public or private aid during the 12-month
period shown in item 8?

D
'

D

Yes (If "Yes," give the following information.)
(Include payments for room and board, for
household expenses, for clothing, for medical
exoenses, etc.)

NAME OF PERSON FOR WHOM
AID WAS GIVEN

No (If "No, "go on to item 16.)

TOTAL
NAME AND ADDRESS OF AGENCY

DATE AND AMOUNT
OF LAST CONTRIBUTION

AMOUNT CONTRIBUTEO
BY EACH

DATE

AMOUNT

'
'

$

$

$

$

$

$

i

'

16. Complete this item if you deposited or withdrew funds from a bank account during the 12-month period
shown in item 8.
TOTAL WITHDRAWALS
DURING PERIOD

TOTAL DEPOSITS MADE
DURING PERIOD

OWNER($) OF ACCOUNT

$

$

$

$

$

$

17. Give the nature and amount of any other funds which were used for support (or saved) during the
12-month period shown in item 8.

~---

'
!

i
'
'
'

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--

Form SSA-760-F4 (11-1983) EF (6-2001)

3.

16. State the nature and amount of your debts, if any, at the end of the period shown in item 8.
(If none, write "None. ")
AMOUNT

DATE INCURRED

DESCRIPTION

$

$
$

19. State any additional facts which you believe tend to show that you were receiving at least one-half of
your support from the worker during the period shown in item 8.

e--. REMARKS:

(This space is for more detailed answers to the above questions, if necessary. If you need more space, attach a separate sheet.)

---------------------·----

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right
to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment or both. I affirm that all information I have
given in this document is true.

SIGNATURE OF APPLICANT
SIGNATURE (First name, middle initial, last name}

DATE (Month, day, year)

(Wr;te ;n ;nk)

SIGN 11o...
HERE Ill"""

TELEPHONE NUMBER (Area Code)

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

ENTER NAME OF COUNTY (if any) IN WHICH
YOU NOW LIVE

Witnesses are only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant making the request must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-760-F4 (11-1983) EF (6-2001)

ADDRESS (Number and street, City, State and ZIP Code}

4.

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 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. 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.