Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody

Social Security Administration

CERTIFICATE OF RESPONSIBILITY FOR WELFARE
AND CARE OF CHILD NOT IN APPLICANT'S CUSTODY

Form Approved
OMB No. 0960-0019

All items on this form requiring an answer must be answered or marked "Unknown."
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
I make this statement in support of my application for insurance benefits payable under Title II of the Social Security Act,
as amended.
1. Give the following information about all unmarried children of the above wage earner or self-employed person who are not
living with you and are: (a) under age 16, or (b) age 16 or over, with a disability that began before age 22. Include natural
children, adopted children, stepchildren, and dependent grandchildren or step-grandchildren.
How Long
NAME, ADDRESS, TELEPHONE
DATE CHILD
From today
NUMBER AND RELATIONSHIP
REASON CHILD
FULL NAME OF CHILD
LEFT YOUR
will the child
(TO CHILD) OF PERSON
LEFT YOUR HOME
HOME
be away
WITH WHOM CHILD
from you?
IS NOW LIVING

2. (a) If you contribute to the support of any child named in item 1 above, give the following information:
FIRST NAME OF CHILD

AMOUNTS CONTRIBUTED

HOW OFTEN YOU CONTRIBUTE

$
$
$
$
(b) If you are not contributing to the support of any child named in 1 above, give name of child and state why you are not
doing so.

Form SSA-781 (06-2015) UF (06-2015)
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3. State how often you do any of the things shown below for any child named in item 1.
FIRST NAME OF CHILD

VISIT

SEND
CLOTHING

MAKE OTHER
GIFTS

WRITE LETTERS

4. Do you give the person or persons with whom the child or children have been placed
instructions for the care of such child or children?

Yes

OTHER (DESCRIBE)

No

If "Yes," explain what those instructions are, how often you give them, and what you do to be sure they are carried out.

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
SIGNATURE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, day, year)
Telephone Number(s) At Which You May Be
Contacted During The Day (include area code)

MAILING ADDRESS (Number and street, P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

Enter Name of County (if any) In Which You Now Live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
2. SIGNATURE OF WITNESS
1. SIGNATURE OF WITNESS
Address (Number and street, City, State and ZIP Code)

Form SSA-781 (06-2015) UF (06-2015)

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

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PRIVACY ACT STATEMENT:
Collection and Use of Personal Information
Section 202 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you
provide to confirm past and continuing eligibility for benefits. Furnishing us this information is voluntary. However, failing to
provide us with all or part of the information could prevent us from making an accurate and timely decision on your eligibility for
benefits, and could result in the loss of some benefits.
We rarely use the information you supply for any purpose other than the reason stated above. 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 Social Security benefits and/or 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 the Census and 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. Information from these matching programs can be used to
establish or verify a person's eligibility for federally-funded or administered benefit programs and 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 Folders Systems,
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.
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 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 only comments relating to our time estimate to this address, not the completed form.

Form SSA-781 (06-2015) UF (06-2015)

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