Form SSA-783 Statement Regarding Contributions

Form SSA-783 (06-2019) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0020

STATEMENT REGARDING CONTRIBUTIONS
All items on this form requiring an answer must be answered or marked "Unknown."
PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

ENTER SOCIAL SECURITY NUMBER

I understand that information given by me will be used in connection with an application for insurance benefits payable under
the provisions of Title II of the Social Security Act, as amended, on the record of the wage earner or self-employed person
named above.
PRINT NAME YOUR FULL NAME (FIRST NAME, MIDDLE INITIAL, LAST NAME)

RELATIONSHIP TO CLAIMANT

PRINT NAME OF CLAIMANT

RELATIONSHIP TO WAGE EARNER
OR SELF-EMPLOYED PERSON

1. (a) Give the following information (for the period indicated below) about each person or agency who contributed to the
claimant's support.
FROM

TO

NAME AND ADDRESS OF
CONTRIBUTORS

RELATIONSHIP TO
CLAIMANT

CONTRIBUTIONS
BEGAN
MO.

YR.

ENDED
MO.

YR.

HOW OFTEN
AVERAGE
MADE
AMOUNT OF
(Weekly, monthly
CONTRIBUTION
or occasionally)
$

$

$
b) Was there any break in contributions by any contributor within the period?
If "Yes," give name of contributor, months in which no contributions were made, and reason:

Yes

No

(c) If any contributions ended before the wage earner's or self-employed person's death or, if living, before application was
contributions
filed, give name of contributor and why he
stopped:stopped:

(d) If other than cash was contributed, such as clothing, board or room, give the following information regarding items supplied
during the period in 1(a).
NAME OF CONTRIBUTOR

ITEMS CONTRIBUTED

APPROXIMATE VALUE

(e) Give name and address of person or agency to which payments were made for claimant's support:

Form SSA-783 (06-2019) UF
2. Did the claimant have wages or income of his or her own?

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Yes

No If "Yes," how much per month? $

IN WHICH MONTHS (Specify)
3. (a) Is claimant a child who lived with more than one parent (Including Stepparents)?
Yes "If "Yes," answer (b), (c) and (d) below

No If "No," go on to item 4

(b) If both parents with whom child lived contributed to child's support, did they use their
monies as one household fund?
If "Yes," how much did each contribute the fund?

Yes

Mother/Father

No
Mother/Father

$

$

(c) If their monies were not combined, what understanding did they have as to how much each would contribute to the
child's support?

(d) What was the monthly income of each?

Mother/Father

Mother/Father

$

$

4. How did you learn of the facts you gave in questions 1,2, and 3?

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 PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)
TELEPHONE NUMBER (Including Area Code)

MAILING ADDRESS (Number and street, Apt No., 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 statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person making the statement must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

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

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

Form SSA-783 (06-2019) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d), 202(h), and 216(e) 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 in determining the child applicant’s
eligibility for benefits.
See Revised Privacy Act Statement Attached
We will use the information to make a determination for eligibility of benefits. We may also share your
information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to have,
information relating to the individual’s capability to manage affairs or eligibility for or entitlement to
benefits under the Social Security program when the data is needed to establish the validity of
evidence or to verify the accuracy of information presented by the individual, and it concerns the
individual’s eligibility for benefits under the Social Security program; and
2. To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash
income maintenance or health maintenance programs (including programs under the Act).
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 Notice (SORN) 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.
See Revised PRA Attached
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.
To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time
estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.