Form SSA-2519 Child Relationship Statement

SOCIAL SECURITY ADMINISTRATION

-=-::~~-=-::~,---------------'''--,

Form Approved
OMB No. 0960-0116

TOE 120

CHILD RELATIONSHIP STATEMENT
WORKER'S SOCIAL SECURITY NUMBER

PRINT WORKER'S NAME

List below all children of 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.)

0

YES

0

NO

0

YES

0

NO

If you answer "YES" to any of the questions under Item 3, submit the document if available or com· plete 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?

0

YES

YES

(d) Did the worker ever list the child as a dependent on a tax return?

0
0

(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?

0

(c) Did the worker ever list the child in a family tree or other family record?

NO

DYES

(f) Did the worker ever make a will listing the child beneficiary?

o

NO

0
0

NO

YES

0

NO

YES

0
0
0

NO
NO

YES

NO

(h) Did the worker ever list the child on any applications for employment?

0
0

(i) Did the worker ever register the child in school or place of worship or sign a report
card as the child's parent?

0

YES

0

NO

0) 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?

0

YES

0

NO

(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?

0

YES

0

NO

(9) Did the worker ever make an allotment for the child while he/she was in military service?

Form SSA·2519 (XX-XXXX) EF (XX-XXXX)
Destroy prior editions

Page

YES
YES

NO

(I)

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.)

DYES D

NO

(m) Is there anyone to whom the worker admitted orally that he/she was the parent of
the child?

DYES

D

NO

(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?

DYES

D

NO

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

Form SSA-2519 (XX-XXXX) EF (XX-XXXX)

Page 2

5. FOR DISTRICT OFFICE USE ONLY
A. Explain all development taken as a result of "YES" answers. Questions 3(1) 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 Re.)
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 (XX-XXXX) EF (XX-XXXX)

Page 3

Privacy Act Statement

Collection and Use of Personal Information

Section 216(h) of the Social Security Act (42 U.S.C. 416(h» authorizes us to collect this information. We will use the
information you provide to help establish the child's relationship to the worker on whose record a claim has been filed.
The information you provide on this form is voluntary. However, failure to provide all or part ofthe requested information
could prevent us from making an accurate and timely decision on your claim.
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.

See revised

We may also use the informationPrivacy
you provide
Actin 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
Statement below.
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 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 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 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send !J.!:J.OCcomments relating to our time estimate to
this address, not the completed form..

Form SSA-2519 (XX-XXXX) EF (XX-XXXX)

Page 4

PRIVACY ACT STATEMENT
Collection and Use of Information
Child Relationship Statement
Section 216 (h)(1))(A)(i) of the Social Security Act, as amended, authorizes us to collect this
information. We will use this information to establish the child’s relationship to the applicant.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlement to benefits. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose the 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 us in establishing rights to Social Security
benefits and coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g.
to the Government Accountability Office and 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, and investigatory activities necessary to assure the
integrity and improvement 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
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice entitled, Claims Folders Systems, 60-0089. This notice, additional information
regarding our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.