Form SSA-1425 Reporting Changes That Affect Your Social Security Payment

Form SSA-1425 or the "Reporting Changes That Affect Your Social Security Payment" is a form issued by the U.S. social security administration.

Download a fillable PDF version of the Form SSA-1425 down below or find it on the U.S. social security administration Forms website.

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Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0073
REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT
USE THIS FORM WHEN THERE IS A CHANGE TO BE REPORTED. ONLY COMPLETE THE ITEM(S) THAT HAVE CHANGED.
PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
LETTER
You should include the letter or letter and number A, B, B2 C, C1,
D, E, F, or H.
Your report cannot be processed without the correct claim number.
DO YOU GET SSI BENEFITS? (Check one)
YES
NO
1.
CHANGE OF ADDRESS (Print new address at bottom)
If Social Security sends your payments to your financial organization,
YES
NO
do you want this to continue?
2.
WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2008?
If you attain full retirement age (FRA) in 2008, your exempt amount is $36,120 ($3,010 a
month) for the months before the month you attain FRA. If you attain FRA in 2009 or
2a) MONTH AND YEAR
later, your exempt amount is $13,560 ($1,130).
a. I am working for wages of more than $1,130 a month (under FRA
COMPLETE BOTH
in 2008) or $3,010 a month (if year of FRA attainment) or performing
BOXES
2b) AMOUNT
substantial services in self-employment beginning with the month of_ _ _ _ _ _ _
$
b. I estimate that my total earnings for this taxable year will be
3.
STOPPING WORK OR LIMITING EARNINGS:
3a) MONTH AND YEAR
a. The last month I worked for wages of more than $1,130 (under FRA in 2008) or
$3,010 (if year of FRA attainment) or performed substantial services in
self-employment was
COMPLETE
3b) AMOUNT
BOTH BOXES
$
b. I estimate that my total earnings for this taxable year will be
4.
CHANGE IN ESTIMATE:
AMOUNT
I estimate that my total earnings for this taxable year will be
$
5.
CHECK if you are self-employed, an officer of a corporation, or related to an
officer of a corporation.
6.
DEATH
7.
DIVORCE
8.
ANNULMENT
DATE OF DEATH:
DATE OF DIVORCE:
DATE OF ANNULMENT:
9.
MARRIAGE
DATE OF MARRIAGE (MO., DAY, YR.)
PRINT NEW LAST NAME
(Place of Marriage) (City, County & State)
CHECK if spouse is now receiving Social Security benefits
IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S
SPOUSE'S CLAIM NUMBER
LETTER
NAME
10.
GOING OUTSIDE THE U.S.
NAME OF COUNTRY TO WHICH GOING
DATE GOING
DATE EXPECT TO RETURN
FOR 30 CONSECUTIVE
DAYS OR LONGER
11.
CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR
DATE LEFT YOUR CARE
CARE OR OTHERWISE CHANGED ADDRESS.
12.
CONFINEMENT OR IMPRISONMENT
DATE OF CONFINEMENT
(MONTH, DAY, YEAR)
Confinement in a jail, prison, or other penal institution or correctional facility, based on a
conviction. Confinement in an institution by court order as a result of certain criminal cases.
13.
GOVERNMENT PENSION OR ANNUITY
13a) MONTH AND YEAR
a. I began receiving a government pension or annuity from the Federal
government or any State or any political subdivision or my present
13b) MONTHLY AMOUNT
payments have changed beginning with the month of
$
COMPLETE BOTH BOXES
b. The amount of government pension or annuity I receive is or has been changed to
14.
RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT
BEGINNING DATE ENDING DATE
AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR
MONTH/YEAR
MONTH/YEAR
ANNUITY, STOPPED.
SIGNATURE OF PERSON MAKING THIS REPORT
DATE SIGNED
NAME OF COUNTRY, IF ANY, IN
NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE
IS THIS A NEW ADDRESS?
WHICH YOU LIVE
Yes
No
CITY, STATE
ZIP CODE
TELEPHONE NUMBER WHERE WE CAN REACH YOU
(INCLUDE AREA CODE)
Form SSA-1425 (04-2008) EF (08-2008) Destroy Prior Editions
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0073
REPORTING CHANGES THAT AFFECT YOUR SOCIAL SECURITY PAYMENT
USE THIS FORM WHEN THERE IS A CHANGE TO BE REPORTED. ONLY COMPLETE THE ITEM(S) THAT HAVE CHANGED.
PRINT NAME OF PERSON OR PERSONS ABOUT WHOM REPORT IS MADE
SOCIAL SECURITY CLAIM NUMBER ON WHICH BENEFITS ARE PAID
LETTER
You should include the letter or letter and number A, B, B2 C, C1,
D, E, F, or H.
Your report cannot be processed without the correct claim number.
DO YOU GET SSI BENEFITS? (Check one)
YES
NO
1.
CHANGE OF ADDRESS (Print new address at bottom)
If Social Security sends your payments to your financial organization,
YES
NO
do you want this to continue?
2.
WORKING AND WILL EARN OVER THE EXEMPT AMOUNT FOR 2008?
If you attain full retirement age (FRA) in 2008, your exempt amount is $36,120 ($3,010 a
month) for the months before the month you attain FRA. If you attain FRA in 2009 or
2a) MONTH AND YEAR
later, your exempt amount is $13,560 ($1,130).
a. I am working for wages of more than $1,130 a month (under FRA
COMPLETE BOTH
in 2008) or $3,010 a month (if year of FRA attainment) or performing
BOXES
2b) AMOUNT
substantial services in self-employment beginning with the month of_ _ _ _ _ _ _
$
b. I estimate that my total earnings for this taxable year will be
3.
STOPPING WORK OR LIMITING EARNINGS:
3a) MONTH AND YEAR
a. The last month I worked for wages of more than $1,130 (under FRA in 2008) or
$3,010 (if year of FRA attainment) or performed substantial services in
self-employment was
COMPLETE
3b) AMOUNT
BOTH BOXES
$
b. I estimate that my total earnings for this taxable year will be
4.
CHANGE IN ESTIMATE:
AMOUNT
I estimate that my total earnings for this taxable year will be
$
5.
CHECK if you are self-employed, an officer of a corporation, or related to an
officer of a corporation.
6.
DEATH
7.
DIVORCE
8.
ANNULMENT
DATE OF DEATH:
DATE OF DIVORCE:
DATE OF ANNULMENT:
9.
MARRIAGE
DATE OF MARRIAGE (MO., DAY, YR.)
PRINT NEW LAST NAME
(Place of Marriage) (City, County & State)
CHECK if spouse is now receiving Social Security benefits
IF SPOUSE RECEIVES SOCIAL SECURITY BENEFITS, FILL IN SPOUSE'S
SPOUSE'S CLAIM NUMBER
LETTER
NAME
10.
GOING OUTSIDE THE U.S.
NAME OF COUNTRY TO WHICH GOING
DATE GOING
DATE EXPECT TO RETURN
FOR 30 CONSECUTIVE
DAYS OR LONGER
11.
CHILD OR OTHER CLAIMANT FOR WHOM YOU RECEIVE BENEFITS IS NO LONGER IN YOUR
DATE LEFT YOUR CARE
CARE OR OTHERWISE CHANGED ADDRESS.
12.
CONFINEMENT OR IMPRISONMENT
DATE OF CONFINEMENT
(MONTH, DAY, YEAR)
Confinement in a jail, prison, or other penal institution or correctional facility, based on a
conviction. Confinement in an institution by court order as a result of certain criminal cases.
13.
GOVERNMENT PENSION OR ANNUITY
13a) MONTH AND YEAR
a. I began receiving a government pension or annuity from the Federal
government or any State or any political subdivision or my present
13b) MONTHLY AMOUNT
payments have changed beginning with the month of
$
COMPLETE BOTH BOXES
b. The amount of government pension or annuity I receive is or has been changed to
14.
RECEIPT OF A PENSION OR ANNUITY BASED ON MY EMPLOYMENT
BEGINNING DATE ENDING DATE
AFTER 1956 NOT COVERED BY SOCIAL SECURITY, OR MY PENSION OR
MONTH/YEAR
MONTH/YEAR
ANNUITY, STOPPED.
SIGNATURE OF PERSON MAKING THIS REPORT
DATE SIGNED
NAME OF COUNTRY, IF ANY, IN
NUMBER AND STREET, APARTMENT NO., P.O. BOX, OR RURAL ROUTE
IS THIS A NEW ADDRESS?
WHICH YOU LIVE
Yes
No
CITY, STATE
ZIP CODE
TELEPHONE NUMBER WHERE WE CAN REACH YOU
(INCLUDE AREA CODE)
Form SSA-1425 (04-2008) EF (08-2008) Destroy Prior Editions
HOW TO REPORT
CONFIDENTIAL INFORMATION
The information you give on this form will be used to
There are three ways to report:
determine if you are still eligible for Social Security
1. PHONE Social Security and explain the change.
benefits and to make sure the amount of your benefit is
correct. Under certain limited conditions authorized by
Telephone Number (
)
law or regulation, Social Security may disclose this
(Area Code)
information to another individual or government agency
2. VISIT Social Security
in order to:
3. MAIL this form to Social Security. Make sure you fill in:
assist Social Security in establishing the right of an
individual to Social Security benefits and/or the
·• NAME of person(s) the report is about
amount of the benefits;
The correct CLAIM NUMBER under which the
facilitate statistical research and audit activities
benefits are payable
necessary to assure the integrity and improvement of
the programs administered by Social Security; and
• Whether the person(s) also receives SSI or Black
Lung benefits.
comply with Federal laws requiring the exchange of
information between Social Security and another
• WHAT is being reported
agency (such as the General Accounting Office and
the Veterans Administration).
• DATE it happened
We may also use the information you give us when we
• Your SIGNATURE and ADDRESS
match records by computer. Matching programs compare
our records with those of other Federal, State, and local
If you mail your report, please use this reporting form and send
government agencies. Many agencies may use matching
it to the nearest Social Security office.
programs to find or prove that a person qualifies for
benefits paid by the Federal government. The law allows
NOTE:
REMEMBER TO TELL US WHEN YOU MOVE,
us to do this even if you do not agree to it.
EVEN IF YOUR MAILING ADDRESS FOR
CHECKS HAS NOT CHANGED.
Explanations about these and other reasons why
information you provide us may be used or given out are
available in Social Security offices. If you want to learn
WHAT TO REPORT
more about this, contact any Social Security office.
The law Sections 202, 203, and 205 of the Social Security Act,
as amended (42 United States Code 402, 403, and 405.)
required you to promptly report certain changes in your
circumstances which could affect your continuing eligibility to
PAPERWORK REDUCTION ACT
benefits or your benefit amount. The kinds of changes you
must report to Social Security are listed on the reverse side of
Paperwork Reduction Act Statement - This information
this form. The booklet, "Your Social Security Rights and
collection meets the clearance requirements of 44 U.S.C.
Responsibilities, "tells more about reporting changes. If you
§3507, as amended by Section 2 of the Paperwork
do not have this booklet or if you want help in making a
Reduction Act of 1995. You do not need to answer these
report, get in touch with any Social Security office. The people
questions unless we display a valid Office of Management
there will be glad to help you.
and Budget control number. We estimate that it will take
about 5 minutes to read the instructions, gather the facts,
SEND OR BRING THE
and answer the questions.
FAILURE TO REPORT
COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U.S.
If you do not report changes in your circumstances, you
Government agencies in your telephone directory or you
may not be paid some, or all, of the benefits due you. Or,
may call Social Security at 1-800-772-1213 (TTY
you may be overpaid, in which case, you will have to pay
1-800-325-0778). You may send comments on our time
back any benefits you received that were not due you.
estimate above to: SSA, 6401 Security Blvd., Baltimore,
MD 21235-6401. Send only comments relating to our
If you hide or do not report a change with the intent to
time estimate to this address, not the completed form.
fraudulently get more benefits or benefits not due you,
you may be fined, imprisoned, or both per Section 208 of
the Social Security Act.
See below for
revised Paperwork
Reduction Act
statement.
Use this form only when there is a change to report to Social Security
Form SSA-1425 (04-2008) EF (08-2008)
Reporting Changes That Affect Your Social Security Payment – Form SSA-1425
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 203, and 205 of the Social Security Act, as amended (42 U.S.C. 402,
403, and 405) authorizes us to collect this information. We will us the information
you provide to assist us in determining your continuing eligibility to benefits or your
benefit amount. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on your claim or could result in the loss of
benefits.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records(e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.
SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - 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 5
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.

Download Form SSA-1425 Reporting Changes That Affect Your Social Security Payment

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