Form SSA-1383 Student Reporting Form

Social Security Administration

TOE 240

Form Approved
OMB No. 0960-0088

STUDENT REPORTING FORM
Use this form only when there is a change to be reported.
PRINT NAME OF STUDENT
LETTER(S)

SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
It is a nine-digit number (000-00-0000) followed by letter(s) C or HC.
We cannot process your report without the correct claim number.
1.

2.

3.

4.

5.
6a.

CHANGE OF ADDRESS (Print new address at bottom of form.)
If the Social Security Administration is sending your payments to your financial
organization, do you want this to continue?

YES

NO

WORKING AND WILL EARN OVER THE EXEMPT AMOUNT
$
for the
year
MONTH AND YEAR
(specify)
(specify)
a. I am working for wages of more than $
a month or performing
substantial services in self-employment beginning with the month of...
FILL IN BOTH BOXES AMOUNT
$
b. I estimate that my total earnings for this taxable year will be...
DATE OF MARRIAGE
MARRIAGE OF STUDENT
(MONTH, DAY, YEAR)
NO LONGER ATTENDING ANY SCHOOL
MONTH, DAY, YEAR
(Do NOT report this item merely because school year ended if you intend to resume
full-time attendance after a vacation period of not more than 4 full calendar months.)
The last day that I attended school on full-time basis was
REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
MONTH, DAY, YEAR
The last day that I attended school on a full-time basis was
CHANGED SCHOOLS - I have arranged to transfer schools effective
full-time
part-time
I am (will be) attending

MONTH, DAY, YEAR

b.

NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records.)

c.

TYPE OF NEW SCHOOL
Secondary (High School level or below)

d.

STUDENT IDENTIFICATION NUMBER

e.

DATE SCHOOL YEAR WILL END

MONTH AND YEAR

STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on

MONTH, DAY, YEAR

7a.
b.
8.

9.

OTHER
Post-secondary (College, Junior
(specify)
College, Trade, or Vocational)
STUDENT'S SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF EMPLOYER
INCARCERATION FOR CONVICTION OF A CRIME
Student is confined in a jail, prison, or other correctional institution
based on a conviction of a crime.
WARRANT ISSUED FOR STUDENT'S ARREST
An unsatisfied warrant was issued for your arrest for a crime or attempted crime of
flight to avoid prosecution or confinement or escape from custody.

DATE OF INCARCERATION
(MONTH, DAY, YEAR)
DATE OF ARREST WARRANT
(MONTH, DAY, YEAR)

SIGNATURE OF PERSON MAKING THIS REPORT
NUMBER AND STREET, APT. NO., P.O. BOX OR RURAL ROUTE
CITY
STATE
ZIP CODE
DATE SIGNED AREA CODE & TELEPHONE NO. (IF ANY) ENTER NAME OF COUNTY, IF ANY, IN WHICH YOU LIVE
Form SSA-1383 (05-2015) UF (05-2015)
Destroy Prior Editions

HOW TO REPORT
There are three ways to report:
1. PHONE Social Security and explain the change.
Telephone Number
(Area Code)
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 student about whom the report is made;
• The correct CLAIM NUMBER under which the
benefits are payable;
• WHAT is being reported;
• 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 kinds of events that you must report to Social Security
are listed on the reverse side of this form. Check any of the
events that apply to you and fill in any other information
requested about the event. If you need more information to
fill out this form, please read "Social Security: What You
Need to Know When You Get Retirement or Survivors
Benefits" and/or "Social Security: What You Need to Know
When You Get Disability Benefits." If you do not have these
publications, or if you want help in making a report,
get in touch with any Social Security office for help.

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 to you.
Also, if you conceal or fail to disclose a reporting event
with an intent to obtain benefits fraudulently 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.

See Revised Privacy Act
Privacy Act Statement Statement Attached
Collection and Use of Personal Information
Sections 202(d), 203(f), and 205(a) of the Social
Security Act, as amended, authorize us to collect this
information. We will use the information you provide to
determine continued entitlement of student benefits
and to determine correct benefit amounts.
Furnishing us this information is voluntary. However,
failing to provide us with all or part of the information
may prevent an accurate and timely decision on any
claim filed.
We rarely use the information you supply us for any
purpose other than to make a determination regarding
benefits entitlement. However, we may use the
information for the administration of our programs
including sharing information: 1. 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); and, 2. To
facilitate statistical research, audit, or investigative
activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of
the Census and to private entities under contract with
us).
A complete list of when we may share your information
with others, called routine uses, is available in our
Privacy Act Systems of Records Notice 60-0089,
entitled, Claims Folder System. Additional information
about this and other system of records notices and
our programs are available online at
www.socialsecurity.gov or at your local Social
Security office.
We may share the information you provide to other
health agencies through 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 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.

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 (OMB) control
number. We estimate that it will take about 6 minutes to
read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

Use this form ONLY when there is a change to report to Social Security.
Form SSA-1383 (05-2015) UF (05-2015)