Fillable SSA-1383 Student Reporting Form

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SSA-1383 Student Reporting Form

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The SSA-1383 Student Reporting Form form is 3 pages long and contains:

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  • 19 check-boxes
  • 32 other fields

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Form SSA-1383 (12-2018) UF
Discontinue Previous Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0088
STUDENT REPORTING FORM
Use this form only when there is a change to be reported.
PRINT NAME OF STUDENT
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID LETTER(S)
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.
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
2.
WORKING AND WILL EARN OVER THE EXEMPT AMOUNT $ for the year.
(specify)
(specify)
2a.
I am working for wages of more than $ a month or performing substantial
services in self-employment beginning with the month of...
MM/YYYY
2b.
FILL IN BOTH BOXES
I estimate that my total earnings for this taxable year will be...
AMOUNT
3.
MARRIAGE OF STUDENT
DATE OF MARRIAGE
(MM/DD/YYYY)
4.
NO LONGER ATTENDING ANY SCHOOL
(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
MM/DD/YYYY
5.
REDUCED SCHOOL ATTENDANCE TO LESS THAN FULL-TIME
The last day that I attended school on a full-time basis was
MM/DD/YYYY
6a.
CHANGED SCHOOLS - I have arranged to transfer schools effective
I am (will be) attending
full-time part-time
MM/DD/YYYY
6b.
NAME AND ADDRESS OF NEW SCHOOL (Give sufficient information for location of your records.)
6c.
TYPE OF NEW SCHOOL
Secondary (High School
level or below)
Post-secondary (College, Junior
College, Trade, or Vocational)
Other (Specify)
6d.
STUDENT IDENTIFICATION NUMBER
STUDENT'S SOCIAL SECURITY NUMBER
6e.
DATE SCHOOL YEAR WILL END
MM/DD/YYYY
7a.
STUDENT'S EMPLOYER IS PAYING STUDENT TO ATTEND SCHOOL
I began attending school as part of my job on
MM/DD/YYYY
7b.
NAME AND ADDRESS OF EMPLOYER
8.
INCARCERATION FOR CONVICTION OF A CRIME Student is confined in a jail,
prison, or other correctional institution based on a conviction of a crime.
DATE OF INCARCERATION
(MM/DD/YYYY)
9.
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 ARREST WARRANT
(MM/DD/YYYY)
Form SSA-1383 (12-2018) UF Page 2 of 3
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
HOW TO REPORT
There are three ways to report:
1. PHONE Social Security and explain the change
2. VISIT any Social Security office
3. MAIL this form to any Social Security office.
Telephone Number (Include Area Code)
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.
Use this form ONLY when there is a change to report to Social Security.
Form SSA-1383 (12-2018) UF Page 3 of 3
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d), 203 (h), and 205(a) 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 an accurate and timely decision
on any claim filed.
We will use the information to determine your entitlement and benefits. We may also share your information for the following
purposes, called routine uses:
1. To third party contacts where necessary to establish or verify information provided by representative payees or payee
applicants; and,
2. To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representative
payees to the extent necessary to pursue Social Security claims and to representative payees when the information
pertains to individuals for whom they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they serve as payees.
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
System. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook
.
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.
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SSA-1383 Student Reporting Form

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Completed 6 May 2020

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