STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE
The information requested on this form is sought pursuant to
authority granted by law (42 U.S.C. 402 and 405). While you
are not required to respond, your cooperation is needed to
confirm your past and/or continuing entitlement to
student benefits.
SOCIAL SECURITY CLAIM NUMBER
NAME AND ADDRESS
Yes No
1. Current School Attendance
(a) Are you now in full-time attendance?
(NOTE: If you are completing this form during a summer break period and you
were in full-time attendance prior to the break and will continue school in the fall, you should answer YES to question 1(a). You should show the
beginning date of the fall semester for question 1(b). See question 2 for past school attendance information.)
(For a change or correction of address, line through the old
address and insert the new address.)
(b) Print School's Name and Address
(c) Type of School Program
(d) Show the number of hours per week you are scheduled to attend
(e) Show your EXPECTED graduation date from SECONDARY school (e.g., high school)
Month,Year
(f) What months between now and your expected graduation will you not be in full-
time attendance for the full month? (For example, months of summer vacation)
2.
Last School Year
(a) Print School's Name and Address
PAST DATES OF ATTENDANCE
(b) Type of School Program
High School
Home School GED Technical
Vocational
Other (Specify):
(c) Show the number of hours per week you were scheduled to attend
Hours
3.
Are you disabled?
Yes
No
4. Are you married?
Yes
No
(If yes, show the date you were married)
Month, Day, Year
5.
(a) Do you expect to earn more than
in year
Yes No
(b) If YES, how much do you expect your total earnings to be in year
?
$
(c) Enter the first month you expect to earn over in year
Month, Year
6.
Are you being paid by your employer to attend school?
Yes
No
7.
Do you have a bank account?
(If yes, attach a voided check or copy of a savings account statement to this form. Student's name must be on the account.)
Yes No
8.
Do you have an unsatisfied warrant for your arrest for a crime or attempted crime of flight to avoid prosecution or
confinement or escape from custody?
Yes
No
I understand that SSA will use the earnings reported to SSA by my employer(s) and my self-employment tax return (if applicable)
as the report of earnings required by law and adjust benefits under the earnings test. I also understand that it is my responsibility
to ensure that the information I give SSA concerning my earnings is correct. I also understand that I must furnish additional
information as needed when my benefit adjustment is not correct based on the earnings on my record.
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 or misleading
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison,
or may face other penalties, or both. I also certify that I have read the detachable information sheet. I authorize my school to
disclose to the Social Security Administration any information concerning my status as a student as it pertains to past, current, or
future Social Security student benefits.
SIGNATURE OF STUDENT
Mailing Address
Student's Own Social Security Number Telephone Number (with area code) Date
School Year Began
Month, Day, Year
School Year Ended
Month, Day, Year
Signature (First Name, Middle Initial, Last Name (Write in ink))
?
School Year Began
Month, Day, Year
School Year Will End
Month, Day, Year
Hours
High School
Home School GED Technical
Vocational
Other (Specify):
Page 2 of 7
OMB No. 0960-0105
Form SSA-1372-BK (12-2017) UF
Discontinue Prior Editions
Social Security Administration
