The purpose of this letter is to advise your office of the following
change(s) with respect to receipt of Social Security benefits by
CHANGE OF ADDRESS
OLD ADDRESS:
ADDR3
NEW ADDRESS:
ADDR3
Effective date:
The following family members will also receive checks or other
information at the new address:
CHANGE OF MARITAL STATUS
married to
divorced from
. Please advise as to the change in benefits, if any, or if additional information is required.
NAME CHANGE
changed
name from
Please forward the necessary form to request a new Social Security card reflecting this name change.
CHANGE IN INCOME OR EARNINGS
has had the following income, earnings or other government benefit change:
BFREE6
This change became effective on
BIRTH OR ADOPTION OF CHILD
A child,
, was
born to
adopted by
A certified copy of the child's birth certificate is enclosed.
Please advise of any additional information that you require in order
to provide benefits for
CHANGE OF CHILD CUSTODY
The custodian has changed for the following child(ren):
PRIOR CUSTODIAN:
ADDR3
As of
, the above named child(ren) will be in the custody of:
NEW CUSTODIAN:
ADDR3
IMPRISONMENT OF BENEFICIARY
was imprisoned at:
ADDR3
. Please advise as to the effect this will have on Social Security benefits.
DEPARTURE FROM UNITED STATES
plans to depart
departed
from the United States on
, for a period of
approximately
days.
Please forward Social Security checks to:
ADDR3
The recipient anticipates returning to the United States on
DEATH OF BENEFICIARY
died on
, a resident of
Enclosed is the decedent's last Social Security check.
Please advise as to the change in the benefits to the following dependents of the decedent:
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
Name:
Relationship:
minor child
disabled child
surviving spouse
surviving ex-spouse
If you have questions or need additional information, please contact me at the address given above.
I can also be contacted by phone at
, extension
, extension
A fax can be sent to
Thank you for your prompt attention to this matter.
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SSCHIN01 OpeningSSCHIN02 Purpose of LetterSSCHIN13 Closing
This required section statesthe names and addresses of theperson requesting informationand the person receiving theletter. Press [Ctrl+F1] formore information.This required section liststhe changes that should bereported to the SocialSecurity Administration(SSA).This required section providesfor a closing paragraph. Theclosing advises the SSA on howto contact the letter writer.
REQUIRED TRANSFER SECTIONCount Field 1 1 1TODATE
REQUIRED OPENING SECTION (SECTION 1 OF 3) [Optional - From Address]
F
R
O
M
T
O
Re: Report of Change for Social Security Number: :
J z
This required section includes the names and addresses of the personrequesting the information and the person to whom the letter will besent. Also included are the reason for the letter and thesalutation. Access the Expert Guide for more information.Enter an X to include the name and address of the person preparingthis letter.Enter the name of the person preparing this letter. Access theExpert Guide for more information regarding notification to theSocial Security Administration of changes.Enter the person's street address or edit the information asdesired.Enter the person's extended street address or edit the informationas desired.Enter the person's city or edit the information as desired.Enter the person's state/province or edit the information asdesired. Press [F8] to select a state from the selection box.Enter the person's zip/postal code.Enter an X to include the person's country.Enter the country or edit the information as desired.Using the format MM/DD/YYYY, enter the date of the letter or editthe date as desired.Enter the personal title and name of the contact person at yourlocal Social Security office. Press F2 to select and paste arecord from the Address Manager.Enter the employment title of the person at the Social Securityoffice.Enter the name of your local Social Security office. This addresscan be obtained from your correspondence with Social Security orfrom your local telephone directory under "Social SecurityAdministration" or "U.S. Government".Enter the street address of the local Social Security office.Enter the extended street address of the local Social Securityoffice.Enter the city in which the Social Security office is located.Enter the state in which the Social Security office is located.Press [F8] to select a state from the selection box.Enter the Social Security office's zip code.Enter an X to include the Social Security office's country.Enter the Social Security offices's country.Enter an X to include a subject matter for this letter.Enter the beneficiary's name as it appears on the Social Securitycard. Access the Expert Guide for information regarding areplacement Social Security card if your card is lost or your namehas changed.Enter the beneficiary's Social Security number as it appears on theSocial Security card. NOTE: Enter numbers only.Enter a salutation or edit the information as desired. Press [F8]to select a salutation from the selection box. If this field or thefollowing name field is left blank, it will not be printed.If previously entered, the contact person's name will be transferredto this field. If desired, you can change the information withoutaffecting earlier data.
Dear Sir or Madam
REQUIRED PURPOSE SECTION (SECTION 2 OF 3) The purpose of this letter is to advise your office of the following change(s) with respect to receipt of Social Security benefits by . [Select the change(s) to be reported: Change of address Change of marital status Name change Change in income, earnings or other government benefit Birth or adoption of a child Change in child custody Imprisonment of beneficiary Departure from the United States for more than 30 days Death of beneficiary]
This required section lists the changes that should be reported tothe Social Security Administration (SSA).Enter the name of the Social Security beneficiary who is reporting achange to the Social Security Administration (SSA). Access theExpert Guide for more information regarding notification to theSSA of changes.Enter an X if the purpose of this letter is to report a change ofthe beneficiary's ADDRESS. Access the Expert Guide for moreinformation regarding an address change.Enter an X if the purpose of this letter is to report a change ofthe beneficiary's MARITAL STATUS. For example, if the beneficiaryhas married or if the beneficiary has become separated or divorced.Enter an X if the purpose of this letter is to report a change ofthe beneficiary's NAME. Access the Expert Guide for moreinformation regarding a name change.Enter an X if the purpose of this letter is to report a change inthe beneficiary's INCOME, earnings or another government benefitreceived by the beneficiary. Access the Expert Guide for moreinformation.Enter an X if the purpose of this letter is to report the BIRTH ORADOPTION of a child by the beneficiary. This information isimportant because additional benefits may be payable as a result ofa birth or adoption.Enter an X if the purpose of this letter is to report a CHANGE INCUSTODY of the beneficiary's child or children. This information isimportant because it may change the amount of benefits paid bySocial Security.Enter an X if the purpose of this letter is to report theIMPRISONMENT of the beneficiary. This information is importantbecause it may affect the benefits payable to the beneficiary.Enter an X if the purpose of this letter is to report that thebeneficiary is DEPARTING from the United States for MORE THAN 30DAYS. Access the Expert Guide for more information regardingdeparture from the U.S.Enter an X if the purpose of this letter is to report the DEATHof a beneficiary. Access the Expert Guide for more informationregarding the death of a beneficiary.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) CHANGE OF ADDRESS OLD ADDRESS: NEW ADDRESS: Effective date: The following family members will also receive checks or other information at the new address: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
This required section gives information about a change of address.Enter the beneficiary's name.Enter the beneficiary's old street address. Access the ExpertGuide for more information regarding a beneficiary's address change.Enter the beneficiary's old extended street address.Enter the beneficiary's old city of residence.Enter the state of the beneficiary's old address. Press [F8] toselect a state from the selection box.Enter the zip code of the beneficiary's old address.Enter an X to include the country of the beneficiary's old address.Enter the country of the beneficiary's old address.Enter the beneficiary's name.Enter the beneficiary's new street address. Access the ExpertGuide for more information regarding a beneficiary's address change.Enter the beneficiary's new extended street address.Enter the beneficiary's new city of residence.Enter the state/postal of the beneficiary's new address. Press [F8]to select a state from the selection box.Enter the zip/postal code of the beneficiary's new address.Enter an X to include the country of the beneficiary's new address.Enter the country of the beneficiary's new address.Using the format MM/DD/YYYY, enter the date the address change waseffective.Enter an X if additional family members also receive Social Securitychecks and also need to report this address change.Enter the name of a family member who receives Social Securitychecks and is also moving from the old address to the new address.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) CHANGE OF MARITAL STATUS On , was married to divorced from . Please advise as to the change in benefits, if any, or if additional information is required.
This required section gives information about a change in maritalstatus; marriage or divorce.Using the format MM/DD/YYYY enter the date of the change in maritalstatus. For example, the date of marriage or the date of a divorcedecree. You will be advised of any change in benefits or anyadditional information required.Enter the name of the Social Security beneficiary who is reporting achange to the Social Security Administration (SSA).Enter an X if the purpose of this letter is to report the marriageof the beneficiary.Enter an X if the purpose of this letter is to report the divorce ofthe beneficiary.Enter the name of the beneficiary's spouse if this letter reportsthe beneficiary's marriage, or ex-spouse if this letter reports thebeneficiary's divorce. If the beneficiary's name has changed, alsoselect the name change option of this letter.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) NAME CHANGE On , changed his/her name from to . Please forward the necessary form to request a new Social Security card reflecting this name change. [Sex: Male Female]
This required section gives information about a change in thebeneficiary's name.Using the format MM/DD/YYYY, enter the date the name change waseffective.Enter the name of the Social Security beneficiary who is reporting achange to the Social Security Administration (SSA).Enter the beneficiary's old name as it appears on the beneficiary'sSocial Security card. Access the Expert Guide for more informationregarding a name change.Enter the beneficiary's new name as it should appear on the newSocial Security card. Access the Expert Guide for information onobtaining a new Social Security card with your new name.Enter an X if the Social Security beneficiary is a male.Enter an X if the Social Security beneficiary is a female.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) CHANGE IN INCOME OR EARNINGS has had the following income, earnings or other government benefit change: This change became effective on .
This required section gives information about a change in thebeneficiary's income or earnings.Enter the name of the Social Security beneficiary who is reportinga change to the Social Security Administration (SSA).Describe the change in the beneficiary's income or earnings, or thechange in another government benefit received by the beneficiary.Access the Expert Guide for additional information regarding thesetypes of changes.Using the format MM/DD/YYYY, enter the date the income change waseffective.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) BIRTH OR ADOPTION OF A CHILD A child, , was born to adopted by on . A certified copy of the child's birth certificate is enclosed. Please advise of any additional information that you require in order to provide benefits for .
This required section gives information about the birth or adoptionof a child.Enter the name of the child born to, or adopted by, the SocialSecurity beneficiary.Enter an X if the purpose of this letter is to report the birth ofa child to the beneficiary. Social Security will advise of anyadditional information required in order to provide benefits forthis child.Enter an X if the purpose of this letter is to report the adoptionof a child by the beneficiary. Social Security will advise of anyadditional information required in order to provide benefits forthis child.Enter the name of the Social Security beneficiary.Using the format MM/DD/YYYY, enter the date the birth or adoptionoccurred.A certified copy of the child's birth certificate is required inorder to receive benefits for the child. Enter an X if the birthcertificate is enclosed. You may use the "Birth Certificate" letterto obtain a certified copy.Enter the name of the child born to, or adopted by, the SocialSecurity beneficiary or edit the information as desired.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) CHANGE OF CHILD CUSTODY The custodian has changed for the following child(ren): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
This required section gives information about a change of childcustody.Enter the child's name. If all children do not reside with the samecustodian, a separate letter should be sent for each child.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) PRIOR CUSTODIAN: As of , the above named child(ren) will be in the custody of: NEW CUSTODIAN:
This required section gives additional information about a changeof child custody.Enter the name of the prior custodian.Enter the prior custodian's street address.Enter the prior custodian's extended street address.Enter the prior custodian's city.Enter the prior custodian's state/province. Press [F8] to select astate from the selection box.Enter the prior custodian's zip/postal code.Enter an X to include the prior custodian's country.Enter the prior custodian's country.Using the format MM/DD/YYYY, enter the date of the change ofcustody.Enter the name of the new custodian.Enter the new custodian's street address.Enter the new custodian's extended street address.Enter the new custodian's city.Enter the new custodian's state/province. Press [F8] to select astate from the selection box.Enter the new custodian's zip/postal code.Enter an X to include the new custodian's country.Enter the new custodian's country.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) IMPRISONMENT OF BENEFICIARY was imprisoned at on . Please advise as to the effect this will have on Social Security benefits.
This required section gives information about the imprisonment ofthe beneficiary.Enter the name of the Social Security beneficiary.Enter the name of the facility where the beneficiary is imprisoned.Social Security will advise as to the effect imprisonment will haveon the benefits.Enter the prison facility's street address.Enter the prison facility's extended street address.Enter the city in which the prison facility is located.Enter the state/province in which the prison facility is located.Press [F8] to select a state from the selection box.Enter the zip/postal code of the prison facility.Enter an X to include the prison facility's country.Enter the country of the prison facility.Using numbers separated by slashes (MM/DD/YY), enter the date thebeneficiary was imprisoned.
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) DEPARTURE FROM THE UNITED STATES plans to depart departed from the United States on , for a period of approximately days. Please forward Social Security checks to: The recipient anticipates returning to the United States on .
This required section gives additional information about theimprisonment of the beneficiary.Enter the name of the Social Security beneficiary who is reportinga change to the Social Security Administration (SSA).Enter an X if the beneficiary plans to depart from the United Statesfor more than thirty days at a future date. Access the Expert Guidefor more information regarding departure from the U.S.Enter an X if the beneficiary has already departed from the UnitedStates for more than 30 days. Access the Expert Guide for moreinformation regarding departure from the U.S.Using the format MM/DD/YYYY, enter the date that the beneficiarywill depart or has departed from the United States.Enter the number of days that the beneficiary will be absent fromthe United States.Enter an X if you want checks forwarded to another address duringthe beneficiary's absence from the United States.Enter the name of the person to whom the beneficiary's checkshould be forwarded during the beneficiary's absence from theUnited States.Enter the street address to which the beneficiary's check should beforwarded during the beneficiary's absence from the United States.Enter the extended street address to which the beneficiary's checkshould be forwarded during the beneficiary's absence from theUnited States.Enter the forwarding address city.Enter the forwarding address state/province. Press [F8] to selecta state from the selection box.Enter the zip/postal code of the forwarding address.Enter an X to include the country of the forwarding address.Enter the country of the forwarding address.Enter an X to include a sentence that states the beneficiary'sexpected date of return.Using the format MM/DD/YYYY, enter the date the beneficiary isexpected to return to the United States.
. J h
CONTINUATION OF REQUIRED PURPOSE SECTION (SECTION 2 OF 3) DEATH OF BENEFICIARY died on , a resident of , . Enclosed is the decedent's last Social Security check. [If dependents were receiving benefits:] Please advise as to the change in the benefits to the following dependents of the decedent: Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other Name: Age: Relationship: minor child disabled child surviving spouse surviving ex-spouse other
This required section gives information about the death of thebeneficiary.Enter the name of the Social Security beneficiary for whom a changeis being reported to the Social Security Administration (SSA).Using the format MM/DD/YYYY, enter the date of the beneficiary'sdeath. Access the Expert Guide for more information regarding thedeath of a beneficiary.Enter the beneficiary's city of residence at the time of death.Enter the state/province where the beneficiary resided at the timeof death. Press [F8] to select a state from the selection box.Enter an X if the beneficiary's last check is being returned withthis letter. No payment is due for the month of death. Forexample, even if a beneficiary dies on the last day of the month,the payment received that month must be returned.Enter an X if dependents of the deceased beneficiary were receivingbenefits (for example, a spouse, a minor child or a disabled adultchild).Enter the name of the dependent who was receiving Social Securitybenefits.Enter the dependent's age.Enter an X if the dependent of the deceased beneficiary is a minorchild.Enter an X if the dependent of the deceased beneficiary is adisabled child.Enter an X if the dependent of the deceased beneficiary is asurviving spouse.Enter an X if the dependent of the deceased beneficiary is asurviving ex-spouse.Enter an X if the dependent of the deceased beneficiary is relatedin another manner.Enter the relationship of the dependent to the deceased beneficiary.
REQUIRED CLOSING SECTION (SECTION 3 OF 3) If you have questions or need additional information, please contact me at the address given above. I can also be contacted by phone at extension or extension . A fax can be sent to . Thank you for your prompt attention to this matter. [Optional enclosure and carbon copy lines]
This required section provides for a closing paragraph. A closingshould state where the information is to be sent and also advisesthe Social Security Administration on how to contact you.Enter an X to request that you be contacted by mail and/or phone.Enter an X to include phone numbers where you can be reached.Enter an X to include a phone number where you can be reachedduring non-business hours.Enter a non-business phone number or edit the information asdesired.Enter an X to include a phone extension number.Enter a phone extension number or edit the information as desired.Enter an X to include a phone number where you can be reachedduring business hours.Enter a business phone number or edit the information as desired.Enter an X to include a facsimile number.Enter a facsimile number or edit the information as desired.Enter a closing or edit the information as desired. Press [F8] toselect a closing from the selection box.The program completes the name by transferring the information froma previous section. If desired, you may change the name withoutaffecting earlier data.Enter an X to include a listing of attachments, enclosures orpersons to whom copies of the letter are being sent.Use this space to enter information regarding enclosures or copiesor press [F8] to select a description from the selection box. Forexample, "Enclosures" or "Copy To".Use this space to enter corresponding information. For example,a description of the enclosure(s) or the name of the party receivinga copy.
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