Form SSA-1372-BK Advanced Notice of Termination of Child's Benefits

Form Approved
OMB No. 0960-0105

SOCIAL SECURITY ADMINISTRATION

ADVANCE NOTICE OF TERMINATION OF CHILD'S BENEFITS
NAME AND ADDRESS

SOCIAL SECURITY CLAIM NUMBER

-

-

NAME OF CHILD BENEFICIARY TO WHOM THIS
STATEMENT APPLIES

DATE CHILD ATTAINS AGE 18

YOUR BENEFITS WILL AUTOMATICALLY STOP AT AGE 18 UNLESS:



You are a full-time student at an elementary or secondary school (a
secondary school is a school at or below the high school level), or
You qualify for childhood disability benefits.

Your benefits will end with the payment for the month before the month in which you attain age 18. You attain age 18
on the day before your 18th birthday. This is important when your birthday is on the first day of the month. For
example, if your 18th birthday is June 1, you attain that age on May 31. If you are neither a full-time student nor
disabled in May, benefits would not be payable for May. The last benefit check to which you would be entitled would
be the one received in May, which represents your payment for April.

FOR YOU TO RECEIVE STUDENT BENEFITS AFTER AGE 18, YOU MUST:
1.
2.
3.
4.

5.

Complete the form, STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE (page 2).
Take the form to the school for a school official to certify on page 3 the information you provide on
page 2.
Leave page 4, NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE, and page 5 with the
school official.
Bring pages 2 (STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE) and 3 (CERTIFICATION
BY SCHOOL OFFICIAL) to a Social Security office or return them in the enclosed envelope (fold page 2
so the address on back shows through window envelope) prior to the age 18 attainment month shown
above.
For Direct Deposit, bring or mail a voided check or a copy of a bank statement. Your name must be on
the account.

TO RECEIVE CHILDHOOD DISABILITY BENEFITS, YOU MUST CONTACT ANY SOCIAL
SECURITY OFFICE AND HAVE THE FOLLOWING INFORMATION:
1.

2.

A history of the disabling condition, including names and addresses of medical record sources (such as
doctors and hospitals) and schools attended. If you have worked, you must also furnish your work
history.
Your Social Security Number.

Please keep the attached sheet, INFORMATION ABOUT BENEFITS PAST AGE 18 (page 6), for your records. It
contains important information about eligibility for student benefits and reporting responsibilities.

Form SSA-1372-BK (06-2009) ef (06-2009)
Destroy Prior Editions

Page 1

Form Approved
OMB No. 0960-0105

SOCIAL SECURITY ADMINISTRATION

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.

NAME AND ADDRESS

SOCIAL SECURITY CLAIM NUMBER

1.

-

(For a change or correction of address, line through the old
address and insert the new address.)

Current School Attendance

No
Yes
(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.)
School Year Began
Month, Day, Year

(b) Print School's Name and Address

High School

(c) Type of School Program

Home School

GED

School Year Will End
Month, Day, Year

Technical

Vocational

Other (Specify):
(d) Show the number of hours per week you are scheduled to attend

Hours

U
Month, Year

(e) Show your EXPECTED graduation date from SECONDARY school (e.g., high school)
(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

(b) Type of School Program

U

PAST DATES OF ATTENDANCE
School Year Began
Month, Day, Year

High School

Home School

GED

School Year Ended
Month, Day, Year

Technical

Vocational

Other (Specify):
Hours

(c) Show the number of hours per week you were scheduled to attend
3.

Are you disabled?

Yes

No

4.

Are you married?

Yes

No

5.

(a) Do you expect to earn more than
in year
?
(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

U

(If yes, show the date you were married)

Month, Day, Year

U
Yes

$

?
.

No

Month, Year

U
6.
7.

Yes

Are you being paid by your employer to attend school?
Yes

Do you have a bank account?

No

No

(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 any unsatisfied felony warrants for your arrest?

9.

Do you have any unsatisfied Federal or State warrants for your arrest for violating the conditions of your probation or parole?
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
SIGN
HERE

First Name, Middle Initial, Last Name (Write in ink)

Mailing Address

U

Student's Own Social Security Number

Telephone Number (with area code)

Form SSA-1372-BK (06-2009) ef (06-2009)

-

(
Page 2

)

Date

-

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0105

CERTIFICATION BY SCHOOL OFFICIAL
Name of Student

Social Security Claim Number

- Please review the information the student provided on page 2, answer the questions below, annotate the
student's expected graduation date on page 4, and sign and date the form in the space provided. You should
give pages 2 and 3 to the student to return to the Social Security Administration. Please retain page 4 for
reporting if the student's full-time attendance ends, or the student graduates, before the date indicated.
1) All information entered in items 1 and 2 of page 2 is correct according to the school's records.
Yes

No

2) Is the school's course of study at least 13 weeks in duration?
Yes

No

3) Please indicate which of the following applies to the school's operating basis.
Yearly
Quarterly/Semester - No Reenrollment Required
Quarterly/Semester - Reenrollment Required

4) I received pages 4 and 5 of this form for reporting changes in the student's attendance.
Yes

No

5) I annotated page 4 of this form with the student's expected graduation date as reported on page 2 of this form.
Yes

No

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.
School
Official
Signs

Title

Printed Name
Date

Phone Number (With Area Code)

(

)

-

The people in your Social Security office will be glad to help you with any questions concerning this form or any other questions
you have about Social Security. For more information, please see: www.socialsecurity.gov/schoolofficials/ .

Form SSA-1372-BK (06-2009) ef (06-2009)

Page 3

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE
The Social Security Administration is authorized to collect information about school attendance under
sections 202(d) and 205(a) of the Social Security Act, as amended (42 U.S.C. 402 and 405). While
completing this form is voluntary, failure to provide all or part of this information is cause for
suspension of benefit payments. The information on this form may be disclosed by the Social Security
Administration to another person or agency for the following purposes: (1) to assist the Social Security
See below for
Administration in establishing the student's right to Social Security benefits, (2) to help with statistical
revised
research and audits necessary to assure
thePrivacy
integrityAct
and improvement of the Social Security programs,
Statement.
and (3) to comply with laws requiring
or allowing the exchange of information between the Social
Security Administration and another agency. This information will be used to verify full-time
attendance in school and to determine continuing eligibility to student benefits.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you give us may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance 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 you about 3 minutes to read the instructions, gather the facts, and answer
the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is 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.

Form SSA-1372-BK (06-2009) ef (06-2009)

Page 5

STUDENT SHOULD DETACH AND KEEP THIS INFORMATION FOR FUTURE REFERENCE

INFORMATION ABOUT BENEFITS PAST AGE 18
If you qualify for Social Security benefits because you are a full-time student, you can start receiving benefits as
early as age 18 and usually through the month you graduate from secondary school, or the month before age 19,
whichever is earlier. Your benefits will be paid in your own name beginning at age 18, either by direct deposit
or by mail. Generally, we consider you to be a full-time student if you are in full-time attendance at a school that
provides education at the secondary (grade 12) level or below. Full-time attendance means you are scheduled to
attend classes at the rate of 20 hours per week, or at the rate determined by your school to be full-time (if
higher).

INFORMATION ABOUT BENEFITS PAST AGE 19
Your benefits may continue past age 19 if you are in actual full-time attendance at a school that provides elementary
or secondary education in the month you become age 19. If the school operates on a yearly basis, then payment may
be continued after age 19 up through the earlier of (1) the month you complete the course in which you are enrolled
full-time or (2) the second month after the month you become age 19. If the school requires re-enrollment on other
than a yearly basis, benefits may continue through the month ending the term that is in progress when you become
age 19. Note that payments beyond age 19 cannot be made if you become age 19 in a month of nonattendance (for
example, you become age 19 in a month when you are on summer vacation).

IMPORTANT RESPONSIBILITIES
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:
 YOU MARRY
 YOU STOP ATTENDING SCHOOL
 YOU REDUCE YOUR SCHOOL ATTENDANCE BELOW FULL-TIME
 YOU CHANGE SCHOOLS
 YOU ARE PAID BY YOUR EMPLOYER TO ATTEND SCHOOL (at the request of or as a requirement

of your employer)
 YOU HAVE ANY UNSATISFIED FELONY WARRANTS FOR YOUR ARREST
 YOU HAVE ANY UNSATISFIED FEDERAL OR STATE WARRANTS FOR YOUR ARREST FOR VIOLATING
THE CONDITIONS OF YOUR PROBATION OR PAROLE

Your benefits may end if any of the above occur. You must report each of these events even if
you believe your benefits should not end. We will tell you about how your benefits may be affected.
YOU SHOULD ALSO NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF:
 YOU MOVE OR CHANGE YOUR MAILING ADDRESS
 YOUR ESTIMATED EARNINGS FROM WORK CHANGE

When you are awarded Social Security benefits as a student, you will receive a booklet that
further covers your responsibilities. It is important for you to read that booklet.
Form SSA-1372-BK (06-2009) ef (06-2009)

Page 6

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE
The Social Security Administration is authorized to collect information about your school attendance under
sections 202(d) and 205(a) of the Social Security Act, as amended (42 U.S.C. 402 and 405). While
completing this form is voluntary, failure to provide all or part of this information is cause for suspension of
benefit payments. The information on this form may be disclosed by the Social Security Administration to
another person or agency for the following purposes: (1) to assist the Social Security Administration in
establishing your right to Social Security benefits, (2) to help with statistical research and audits necessary
See below for
to assure the integrity and improvement of the Social Security programs, and (3) to comply with laws
revised Privacy Act
requiring or allowing the exchange of information between the Social Security Administration and another
Statement.
agency. This information will be used to verify full-time attendance in school and to determine continuing
eligibility to student benefits.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the
Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you give us may be used or given
out are available in Social Security offices. If you want to learn more about this, contact any Social Security
office.

PAPERWORK REDUCTION ACT: This information collection meets the clearance 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 you about 8 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is 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.

Form SSA-1372-BK (06-2009) ef (06-2009)

Page 7

Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d) and 205(a) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to verify full-time attendance in school
and to determine whether children of an insured worker are eligible for student benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefit eligibility. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled, Claims Folder System.
Additional information about this and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.