Form SSA-5-INST (07-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 2
OMB No. 0960-0003
REPORTING RESPONSIBILITIES FOR MOTHER'S OR FATHER'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 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 or immigration status changes.
• You go outside the U.S.A. for 30 consecutive days
or longer.
• Any beneficiary dies or becomes unable to
handle benefits.
• Work Changes - On your application you told us you
expect total earnings for to be
$ .
You earning wages of more than
$ a month.
(are) (are not)
You self-employed rendering
substantial services in your trade or business.
(are) (are not)
(Report AT ONCE if this work pattern changes)
• Change of Marital Status - Marriage, divorce, annulment of
marriage. You must report marriage even if you believe
that an exception applies.
• Custody Change or Disability Improves - Report if a
person for whom you are filing, or who is in your care dies,
leaves your care or custody, changes address, or, if
disabled, the condition improves.
• 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 begin to receive a retirement or disability government
pension or annuity (from the Federal government or any
State or any political subdivision thereof) or your pension
or annuity amount changes.
• You have an unsatisfied felony or arrest warrant for more
than 30 continuous days fro flight to avoid prosecution or
confinement, escape from custody, or flight escape.
WORK AND EARNINGS
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 and 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.
You can make your 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.
HOW TO REPORT
NOTICE ABOUT DOCUMENTS
We recommend that you keep all documents you submitted to us.
We are returning the documents you submitted with this claim.
