Medicare-only Paper Form SSA-1

Form Approved
OMB No. 0960-0007

REPORTING RESPONSIBILITIES FOR RETIREMENT INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES

You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)

Your stepchild is entitled to benefits on your record
and you and the stepchild's parent divorce.
Stepchild benefits are not payable beginning with
the month after the month the divorce becomes
final.

Your citizenship or immigration status changes.

Custody Change — Report if a person for whom you
are filing, or who is in your care dies, leaves your
care or custody, or changes address.

You go outside the U.S.A. for 30 consecutive days
or longer.
Any beneficiary dies or becomes unable to handle
benefits.
Work Changes — On your application you told us
you expect total earnings for
to be
(Year)
$_____________.
You
than $

(are)

(are not) earning wages of more
a month.

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.

Change of Marital Status — Marriage, divorce,
annulment of marriage.
HOW TO REPORT
online,
by telephone,
mail,
You can make your reports by
telephone,
mail,
or orinin
person, whichever you prefer.

If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:
Calling us TOLL FREE at 1-800-772-1213.
If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or

(Report AT ONCE if this work pattern changes)
You are
to atojail,
prison,
penal
institution
or
You
areconfined
confined
jail,
prison,
penal
institution
or
correctional facility
for more
than 30 continuous
daysor
foryou
correctional
facility
for conviction
of a crime
conviction
of a to
crime,
or youinstitution
are confinedby
forcourt
more than
are
confined
a public
order30in
connection
withto aa crime.
continuous days
public institution by a court order in
connection with a crime.

You
becomeentitled
entitled
a pension
or annuity
based
You become
to ato
pension,
an annuity,
or a lump
sum
on
your based
employment
after 1956
not covered
by
payment
on your employment
not covered
by Social
Social
Security,
or
if
such
pension
or
annuity
stops.
Security, or if such pension or annuity stops.
You have an unsatisfied warrant for more than 30 continuous days

You
have an unsatisfied warrant for your arrest for
for your arrest for a crime or attempted crime that is a felony of flight
ato crime
or attempted
crime escape
that isfrom
a felony
(or, in
avoid prosecution
or confinement,
custody and
jurisdictions
not define
crimes
as felonies,
flight-escape. Inthat
mostdo
jurisdictions
that do
not classify
crimes as a
crime
is that
punishable
bybydeath
imprisonment
felonies,that
a crime
is punishable
death ororimprisonment
for a
for
term exceeding
1 year.)of the actual sentence
termaexceeding
one year (regardless
imposed).

You
haveanan
unsatisfied
warrant
forthan
a violation
of
You have
unsatisfied
warrant
for more
30 continuous
probation
or parole
under Federal
or under
StateFederal
law. or
days for a violation
of probation
or parole
State law.

Calling, visiting or writing your local Social
Security office at the phone number and address
shown on your claim receipt.

► Visiting the section “my Social Security” at our web site at
www.socialsecurity.gov.”

For general information about Social Security, visit our
web site at www.socialsecurity.gov.
For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount. You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if
applicable) as the report of earnings required by law, to
adjust benefits under the earnings test. It is your
responsibility to ensure that the information you give
concerning your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

NOTICE ABOUT DOCUMENTS
copies
of all documents
you submitted
to us.
We recommend that you keep all
documents
you submitted
to us.

We are returning the documents you submitted with this claim.

Form SSA-1-INST (3-2006) EF (03-2006) Destroy prior editions

Page 1

Collection and Use of Information From Your Application
Privacy Act Notice/Paperwork Reduction Act Notice
The Social Security Administration is authorized to collect the information requested on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You
do not have to give us the requested information. However, if you do not provide the information, we will be
unable to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to
benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency for
determining eligibility for a government benefit or program, to a Congressional office requesting information on
your behalf, to an independent party for performance of research and statistical activities, or to the Department of
Justice for use in representing the Federal government.
We may also use this information 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. See Revised Privacy Act and PRA Statements Attached
Explanations about these and other reasons why information you provide 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 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 10.5
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. 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.

Form SSA-1-INST (3-2006) EF (03-2006 )Destroy prior editions

Page 2

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Collection and Use of Personal Information
Privacy Act Statement
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine if you or a dependent is
eligible to insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, if you fail to provide all or part
of the requested information, we will be unable to make an accurate and timely decision
concerning your entitlement or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than for determining continuing
eligibility. However, we may use it for the administration and integrity of our 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 us in establishing rights to our 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, or investigative activities necessary to assure the
integrity and improvement of our programs. (e.g., to the Bureau of Census and to
private entities under contract with us).
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. We use the information from these matching programs to establish or verify a person's
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of
Records Notices entitled, Earnings Recording and Self Employment Income System (60-0059)
and Claims Folders Systems (60-0089). Additional information regarding these and other
systems of records notices, are available on-line at www.socialsecurity.gov or at your local
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 11 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 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to our time
estimate to this address, not the completed form.