TN 15 (01-03)
RS 00205.735 Form SSA-1372 BK
The SSA-1372-BK serves as the primary form for developing a student's FTA at an EI and for verifying the student's continuing FTA. An SSA-1372-BK is sent to each child beneficiary 3 months before he or she attains age 18. It explains the conditions under which benefits can continue after age 18 and what he or she must do to pursue his or her claim for benefits as a student or disabled child. In initial claims, it is given to the student at the time the application for child's benefits is completed if the child:
meets the requirements for child's benefits; and
is at least age 17 years and 6 months (or will be at least that age when the claim is processed), it is given to the student at the time the application for child's benefits is processed.
It is the student's responsibility to:
complete the Student’s Statement Regarding School Attendance portion of Form SSA-1372-BK; or if attending school outside of the United States, complete Form SSA-1372-BK-FC.
have a school official complete the Certification By School Official portion of page 3 of the form; and
give the Notice of Cessation of Full-Time School Attendance (page 4 of the form) to a school official for return to SSA if the student ceases to be in FTA.
Failure to submit a completed SSA-1372-BK, or its equivalent, is considered failure to establish FTA at an EI.
C. Description of the SSA-1372-BK
The SSA-1372-BK is a 7-page form consisting of:
1. Page 1 - Advance Notice of Termination of Child's Benefits
This explains the conditions under which benefits can be paid after the child beneficiary reaches age 18. It contains essentially the same information as the Form SSA-1387-FC-EP (Advance Notice of Termination of Child's Benefits) that is sent to the child's representative payee at the same time that the SSA-1372-BK is sent to the child beneficiary. It also provides instructions on completion of the form.
2. Pages 2 and 3 - Student's Statement Regarding School Attendance
This portion of these pages asks for information from the student about his or her school attendance and his or her eligibility for benefits.
3. Page 3 - Certification by School Official
This certification is to be completed by an official of the school the student is attending, to confirm the information provided on the student's statement.
4. Page 4 - Notice of Cessation of Full-Time Attendance
The student gives this page to the school official. The instructions on this page request the school official to complete the form when the student ceases to be in FTA. The school official is to check the appropriate items on the form to show the date and reason the student's FTA ceased. The school is requested to send the completed form to SSA.
5. Page 5 - Privacy Act/Paperwork Reduction Act Notice
This information is for the school official and relates to completion of notice of cessation of FTA.
6. Page 6 - Information About Benefits Past Age 18
This page contains important information for the student about the payment of benefits after age 18 and his or her reporting responsibilities.
7. Page 7 - Privacy Act/Paperwork Reduction Act Notice
This information relates to the student claim and related form.
D. Exhibit - Form SSA-1372-BK
To view the form, go to SSA-1372–BK.