Download Form SSA-1372-BK "Advance Notice of Termination of Child's Benefits"
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8Form SSA-1372-BK (12-2017) UF
Page 1 of 7
Discontinue Prior Editions
Social Security Administration
OMB No. 0960-0105
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.
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
2.
on page 2.
Leave page 4, NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE, and page 5 with
3.
the school official.
Bring pages 2 (STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE) and 3
4.
(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.
5.
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:
A history of the disabling condition, including names and addresses of medical record sources
1.
(such as doctors and hospitals) and schools attended. If you have worked, you must also furnish
your work history.
2.
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 (12-2017) UF
Page 1 of 7
Discontinue Prior Editions
Social Security Administration
OMB No. 0960-0105
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.
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
2.
on page 2.
Leave page 4, NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE, and page 5 with
3.
the school official.
Bring pages 2 (STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE) and 3
4.
(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.
5.
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:
A history of the disabling condition, including names and addresses of medical record sources
1.
(such as doctors and hospitals) and schools attended. If you have worked, you must also furnish
your work history.
2.
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 (12-2017) UF
Page 2 of 7
Discontinue Prior Editions
OMB No. 0960-0105
Social Security Administration
STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE
The information requested on this form is sought pursuant to
NAME AND ADDRESS
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
(For a change or correction of address, line through the old
address and insert the new address.)
1.
Current School Attendance
(a) Are you now in full-time attendance?
Yes
No
(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
School Year Will End
(b) Print School's Name and Address
Month, Day, Year
Month, Day, Year
Vocational
Home School
GED
Technical
(c) Type of School Program
High School
Other (Specify):
Hours
(d) Show the number of hours per week you are scheduled to attend
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)
Last School Year
2.
PAST DATES OF ATTENDANCE
(a) Print School's Name and Address
School Year Began
School Year Ended
Month, Day, Year
Month, Day, Year
Vocational
Home School
GED
Technical
High School
(b) Type of School Program
Other (Specify):
Hours
(c) Show the number of hours per week you were scheduled to attend
3.
Are you disabled?
Yes
No
Month, Day, Year
4.
Are you married?
Yes
(If yes, show the date you were married)
No
5.
?
Yes
No
(a) Do you expect to earn more than
in year
? $
Month, 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
No
Yes
6.
Are you being paid by your employer to attend school?
Do you have a bank account?
Yes
No
7.
(If yes, attach a voided check or copy of a savings account statement to this form. Student's name must be on the account.)
Do you have an unsatisfied warrant for your arrest for a crime or attempted crime of flight to avoid prosecution or
8.
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
Signature (First Name, Middle Initial, Last Name (Write in ink))
Student's Own Social Security Number
Telephone Number (with area code)
Date
Form SSA-1372-BK (12-2017) UF
Page 3 of 7
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/.
SCHOOL SHOULD DETACH AND RETAIN THIS FORM
Form SSA-1372-BK (12-2017) UF
Page 4 of 7
Field Office Name and Address
NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE
SOCIAL SECURITY CLAIM NUMBER
NAME OF SOCIAL SECURITY BENEFICIARY
DATE OF BIRTH
STUDENT'S EXPECTED
STUDENT'S SOCIAL SECURITY NUMBER
MONTH, YEAR
GRADUATION DATE
(FROM PAGE 2)
INDIVIDUAL IDENTIFIED ABOVE CEASED TO BE A FULL-TIME STUDENT AT THIS SCHOOL ON (MONTH, DAY, YEAR)
REASON:
1.
Withdrawal, suspension, or expulsion
2.
Changed to part-time status
3.
Failed to continue in full-time attendance at start of new term (or new school year)
4.
Other (Explain)
NAME AND ADDRESS OF SCHOOL
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.
SIGNATURE (OR FACSIMILE) OF SCHOOL OFFICIAL
PRINTED NAME
TITLE
DATE
IMPORTANT INFORMATION ABOUT THIS FORM
This form contains the name, date of birth, and Social Security claim number of a child beneficiary who tells us that he/she
is (or will be when school resumes) a full-time student at your school. One of the conditions a child between 18 and 19
must meet to receive Social Security benefits is that he/she be a full-time student.
Full-Time Attendance
For Social Security purposes, a student in “full-time attendance” is one who is attending an elementary or secondary
school and is enrolled in a day or evening non-correspondence course at least 13 weeks in duration. In addition, the
student must be scheduled to attend at the rate of at least 20 hours weekly and be carrying a subject load that is
considered full-time for day students under the school's standards and practices. If there is any question about whether a
student's attendance is full or part-time, please apply your school's usual criteria.
What to Report
Please hold this form until the student is no longer a full-time student at your school (whether this is during the current
school year, at the start of the next school year, or any time after that). Then, enter the date he/she stopped being a full-
time student, check the appropriate box above and return the completed form to the Social Security office shown above.
You should not return the form to report that attendance stopped for a scheduled break (e.g., summer break) unless you
do not expect the student to return after the break. You should report if the student stops attending school full-time,
or graduates, earlier than the expected graduation date shown above. 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/.
Thanks for your coorperation.
Form SSA-1372-BK Instructions
The Social Security Termination of Child Benefits Form must be completed by you and the school official. It is your responsibility to ensure the school official completes the required form and to submit the completed and certified pages of the document to the SSA. You can find detailed filing instructions on the first page of the form and on the SSA website. Step-by-step instructions are provided below.
How to Fill out Form SSA-1372-BK?
Form SSA-1372-BK consists of 7 pages in total. Only two of them (pages 2 and 3) should be completed and returned to the SSA. The student has to fill out page 2 of the form, Student's Statement Regarding School Attendance, as follows:
- Provide information about your current school attendance. Indicate the school's name, address, dates of beginning and termination of the school year, type of school program, number of hours per week you are required to attend school, your secondary school expected graduation date and months during which you will not be at FTA;
- Indicate the details about the last school year, including the school's name, address, past dates of attendance, type of school program, and number of hours per week you had to attend;
- Specify if you are disabled;
- Specify if you are married;
- Provide the information on your expected earnings;
- Specify if the employer pays you for attending school;
- Specify if you have a bank account. If yes, attach a copy of a savings account statement or a voided check with your name on it to the form;
- Specify if you have any unsatisfied warrant for arrest for a crime or crime attempt;
- Sign the document. Provide your contact information and indicate the completion date.
Take the form to the school official for certification. The school official must review the information you have provided on page 2, certify page 3, Certification by School Official, and return you both pages. Besides, the school official is required to detach and keep pages 4 and 5. Page 4, Notice of Cessation of Full-Time School Attendance, will be completed and returned to the SSA when you cease to be in FTA.
You should detach and keep pages 6 and 7 with the information about benefits and responsibilities for future references. You are not obliged to complete the form. However, failure to submit it is considered as a failure to establish FTA and leads to termination of your benefits.
Where to Send Form SSA-1372-BK?
Mail the completed form in the enclosed envelope to your local Social Security office for processing. The address of your local Social Security office should be printed on the form. If the address is missing, you can obtain it from the SSA official website.
