Application for Parent's Insurance Benefits / Modernized Claims System (MCS) / Signature Proxy / SSA-7-F6/ and Preliminary Claims System (PCS)

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REPORTING RESPONSIBILITIES FOR PARENT'S 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 have an unsatisfied felony or arrest
warrant for more than 30 continuous days for
flight to avoid prosecution or confinement,
escape from custody, or flight escape.

...... 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 citizenship
changes.

or immigration status

...... You go outside the U.S.A.
consecutive days or longer.

for

...... Xe\:! ha�fied warrant-fer-a
violation of probation or parole uooer
Eederal or State law. \;:)-� \ t \--e. Bv1. \ \ -e.T

30

...... Any beneficiary dies or becomes unable to
handle benefits.

WORK AND EARl)IINGS
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.

...... Work Changes - On your application you
told us you expect total earnings for
to be $ ____
Year
You (are) (are not) earning wages of more
a month.
than $
You (are) (are not) self-employed rendering
substantial services in your trade or
business.
(Report AT ONCE if this work pattern 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.
...... Change of Marital Status
Marriage,
divorce or annulment of marriage even if
you believe that an exception applies.

HOW TO REPORT

...... You are confined to jail, prison, penal
institution or correctional facility for more than
30 continuous days for conviction of a crime
or you are confined for more than 30
continuous days to a public institution by
court order in connection with a crime.

You can make you reports by telephone,
mail, or in 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
� Calling, visiting or writing your local Social
Security office at the phone number and
address shown on your claim receipt.
For general information about Social Security,
visit our web site at www.socialsecurity.gov.

Form SSA-7-INST (1-2010) EF (01-2010)

Page 1

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

O

We are returning all the documents you submitted with this claim.
Collection and Use of Information from Your Application See Revised Privacy
Privacy Act Notice
Act Statement Attached

The Social Security Administration is authorized to collect the information on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide on this form will be used
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.
As permitted under 5 U.S.C. § 552a(b) of the Privacy Act, as amended, SSA may disclose the
information you provide ( 1) to another Federal, State or local government agency for determining
eligibility for a government benefit or program; (2) to a Congressional office requesting information on
your behalf; (3) to comply with Federal laws requiring the disclosure of the information from our
records; and (4) to facilitate statistical research, audit or investigative activities necessary to ensure
the integrity of SSA programs.
We may also use the information you give us 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.
Explanations about these and other reasons why information you provide us 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 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. The office is 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-7-INST (1-2010) EF (01-2010)

Page 2

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 205, 223, 226, and 806 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent us from making an accurate and timely decision on your
entitlement to Social Security benefit payments.
We will use the information to determine your eligibility for Social Security benefits. We may
also share your information for the following purposes, called routine uses:


To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act). Such disclosures include, but are not limited to, release of information to:
Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance
Act and for administering provisions of the Social Security Act relating to railroad
employment; and Department of Veterans Affairs for administering 38 U.S.C. 1312, and
upon request, for determining eligibility for, or amount of, veterans benefits or verifying
other information with respect thereto pursuant to 38 U.S.C. 5106; and



To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under the routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0059, Earnings Recording and Self-Employment Income System, as published in the
Federal Register (FR) on January 11, 2006, at 71 FR 1819; 60-0089, entitled Claims Folders
Systems, as published in the FR on April 1, 2003, at 68 FR 15784; 60-0090, entitled Master
Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and 60-0321,
entitled Medicare Database, as published in the FR on July 25, 2006, at 71 FR 42159.
Additional information and a full listing of all our SORNs are available on our website at
www.ssa.gov/privacy.