SSA-1372-BK

This form has to be viewed and/or downloaded in .pdf format. You may download it from Adobe.

All 7 pages of form SSA-1372-BK are available for viewing/downloading. Pages 1, 6 and 7 are provided as informational for school officials. Pages 2, 3, 4 and 5 directly concern school officials. Below are descriptions of each of the pages:

SSA-1372-BK, page 1

Page 1 informs the child that his/her benefits will stop at age 18 unless he/she qualifies for childhood disability benefits or is a full-time student at an elementary or secondary school. It also states what the child should do to receive student or childhood disability benefits.

SSA-1372-BK, page 2

Page 2 consists of the student's information about current and prior school attendance and an expected graduation date, and it elicits information about other factors that may affect the payment of benefits. When a student completes page 2, he or she should give it to a school official for review.

SSA-1372-BK, page 3

Page 3 is the school official's certification of the student's information about his or her school attendance. The school official should:

• Review the information the student provided on page 2;
• Answer the questions on page 3;
• Sign and date page 3, furnishing the school official's title and phone number with area code;
• Annotate page 4 with the student's expected graduation date;
• Keep pages 4 and 5; and
• Return the rest of the form to the student.

SSA-1372-BK, page 4

The school official should detach and retain this page. He or she should keep page 4 for the purpose of reporting that a student is no longer in full-time attendance. If the student does not leave page 4, the school official should download it from this site.

NOTE: If the student leaves page 4 with the school, the form should have the address of the student's local Social Security office printed on it. If that information is missing, or if the school official downloads page 4 from this site, the school official can obtain the address of the student's local Social Security office. The school official should input the student's zip code.

SSA-1372-BK, page 5

Page 5 consists of a Privacy Act/Paperwork Reduction Act notice and a Paperwork Reduction Act statement for school officials.

SSA-1372-BK, page 6

Page 6 provides information to the student about benefits past age 18, benefits past age 19, and events the student must report to SSA.

SSA-1372-BK, page 7

Page 7 consists of a Privacy Act/Paperwork Reduction Act notice and a Paperwork Reduction Act statement for students.