Fillable Ssa-2519 Child Relationship Statement

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Ssa-2519 Child Relationship Statement

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Form SSA-2519 (08-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0116
Privacy Act Statement
Collection and Use of Personal Information
Section 216(h)(3) of the Social Security Act, as amended, allows 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 regarding Social Security benefits. We will use the information to determine eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
• To third party contacts, where necessary, to establish or verify information provided by representative payees or
payee applicants; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting Social Security Administration
in the efficient administration of its programs.
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, as published in the Federal Register
(FR) on April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is available on our
website at www.ssa.gov/privacy.
- 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. 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.
Paperwork Reduction Act Statement
WAGE EARNER'S SOCIAL SECURITY NUMBERPRINT WAGE EARNER'S NAME
List below all children of the wager earner (hereafter referred to as the worker) for whom you are requesting benefits.
NAME OF CHILD OR CHILDREN
A child of the worker may be entitled to benefits if: (1) the worker was decreed by court to be the child's parent; or (2)
the worker was ordered by a court to contribute to the child's support because the child is his or her son or daughter;
or (3) the worked acknowledged in writing that the child is his or her son or daughter; or (4) the child is living with or
receiving contributions from his or her parents at certain times. The questions below are designed to help Social
Security determine if the child can meet these requirements. Please use item 4 on the reverse of this form for any
comments you wish to make.
1. Was the worker ever decreed by a court to be the child's parent?
If "YES," please submit a copy of that decree or give use the name of the court and the date of the decree.
(If "YES," omit items 2, 3, and 4.)
Yes No
2. Was the worker ever ordered by a court to contribute to the child's support because the
child was his or her son or daughter?
If "YES," please submit a copy of that decree or give us the name of the court and the date of the decree.
(If "YES," omit items 3 and 4.)
NoYes
If you answer "YES" to any of the questions under Item 3, submit the document if available or complete Item 4
on the reverse side of this form. If you are unsure of an answer explain in Item 4.
IN ALL CASES COMPLETE NAME AND ADDRESS BLOCK ON THE OTHER SIDE OF THE FORM.
Child Relationship Statement
(h) Did the worker ever list the child on any applications for employment?
(i) Did the worker ever register the child in school or place of worship or sign a
report card as the child's parent?
(j) Did the worker ever take the child to a doctor's or dentist's office or to a hospital
and list himself/herself as parent?
(k) Did the worker accept responsibility for or pay the child's hospital expenses at
birth or did he/she give the information for the child's birth certificate?
(l) Do you know of any other written evidence of any kind which would show that
the child is the son or daughter of the worker? (The information need not have
been supplied by the worker.)
(m) Is there anyone to whom the worker admitted orally that he/she was the parent
of the child?
(n) Is the worker making regular and substantial contributions to the child's support
or was the worker making such contributions at that time the worker died?
Form SSA-2519 (08-2019) Page 2 of 3
3. (a) Did the worker ever file an application with or make a statement to the Veterans
Administration or welfare office or to any government agency in which he/she stated
the child was his/hers?
NoYes
(b) Has the worker written any letters to anyone that you know of in which he/she may have
referred to the child as a son or daughter or referred to himself/herself as the child's
parent?
NoYes
(c) Did the worker ever list the child in a family tree or other family record?
No
Yes
(d) Did the worker ever list the child as dependent on a tax return?
NoYes
(e) Did the worker ever take out any insurance policies on the child or make the
child a beneficiary of his/her own insurance policy?
NoYes
(f) Did the worker ever make a will listing the child beneficiary?
NoYes
(g) Did the worker ever make an allotment for the child while he/she was in military
service?
NoYes
NoYes
NoYes
No
Yes
NoYes
NoYes
NoYes
NoYes
4. If you answered "YES," to any of the questions in Item 3 identify the question (e.g., "3(a)") and supply detailed
information below. For example: You should provide the names and addresses of government agencies, doctors,
hospitals, schools, etc. where appropriate. The approximate date of the event and the surrounding circumstances
should be indicated. The information should be in sufficient detail to enable us to locate the document or evidence
remembering the final responsibility for supplying this evidence is yours. Where more than one child is filing for
benefits identify below the child to whom the evidence pertains.
NAME OF PERSON COMPLETING FORM
ADDRESS (NUMBER AND STREET OR P.O. BOX, OR RURAL ROUTE)
CITY AND STATE
DATE
TELEPHONE NO. & AREA CODE
ZIP CODE
Form SSA-2519 (08-2019) Page 3 of 3
5. FOR DISTRICT OFFICE USE ONLY
(a). Explain all development taken as a result of "YES" answers. Questions 3 (l) and 3 (m) are designed to uncover
sources of "Other Evidence" of parentage where the child was living with or receiving contributions from the
worker at the appropriate times, or to uncover other sources of an acknowledgement in writing by the worker.
(b). Outline all other pertinent relationship development made on this claim. (This suffices for the required RC.)
When considering the status of an out-of-wedlock child, you may not disallow the child until you consider
applicable State intestacy law.
State of Domicile:
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Ssa-2519 Child Relationship Statement

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Completed 18 November 2019

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