Form Approved SOCIAL SECURITY ADMINISTRATION (OME No. 0960-0105 STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE NAME AND ADDRESS VANCE CORBETT FOR DAKOTA} RIVELLI CORBETT 13661 § 287TH BAST AVE COWRTA OK 72029-1024 Th infanmalon Fea ranted bylaw (2 22RT996196382 1] Gurrent school attendance dorm an ner he new addres ) Ave you vow in flltine attendance? BQ Yes © ET No (NOTE: tt you are competing this form durin ind an you wert In fulone attendance Pr to the Treak and wil condanueschaal i the all you shou ener TES tp {Rue 10) "You should show Ue beginning date of the fal semester far quezan Mo). See question # ar ast school attendance Snformation) Pant Shots pe at Aras School Year Bogan] School Year ‘3 Coweta hk School Month. Day. Year _| Month, Day Pyos $. 365 E.hve Covel Of 74429 (© Type of School Program (BQ High School [J Home School [J GED L] Te Dlotner specifi. (@ Show the number of hows per week you are scheduled to attend o6get00 wnical [J Vocational (© What months between now and your expected graduation will you not be in fulltime ‘attendance for the fall month? (For example, months of summer vacation >| 2_| Cast School Year PAST DATES OF ATTENDANCE, (a) Print School's Name and Address ‘School Year Began | School Year Ended ‘Monch, Day. Year_| Month, Day, Year @) Type of School Program igh School [] Home School [] GED [J Technical [J Vocational Other Specify (©) Show the number of hours per week you were scheduled to attend Hours ——E ble? 1 Yes_ EX No ‘Are you married? D1 Yes [EINo Af yes, show the date you were married) [_Menth. Day. Year” “oy &_| (@) Do you expect to earn more than$19560.00 in vear 20227 Dyes Eine (0) IFYES, how much do you expect your total earnings to be in year 20227 | Month. Year (©) Entor the first month you expect to earn over$1630,00in year 2022, ——a &._| Are you being paid by your employer to attend school? Dye (No fe 7 | Do you have a bank accom? L] Yes QNo If yes, attach a voided check or copy of a savings account statement 10 thie form. Student's name must be on the account. ‘Are you dis Do yo have wv unsatisfied warvant for Your wrest for cine or altanplad cre of fight to avoid promeution or contnemert ot wvape fom eum? Dy (Ne 1 understand that SSA will use the earnings reported to SSA by my employer(s) and my selfemployment tax return Gf applicable) fas the report of earnings required by Taw and adjust benefits under the earnings test. also understand that it is my responsibility {to ensure that the information T give SSA concerning my earnings i8 correct. also understand that T must furnish additional Information as needed when my Benefit adjustment it not correct based on the earnings on mly tecord, T declare under penalty of periury that | have examined all the formation on this form, and an any acc snd itis trun and correct to the hest af my knowledge. understand that anyone who knowingly gives s fnlee or tlslending statement sbout » material fact im this information, oF causes someone else to do #0, commits «crime ‘be sent to prison, or may face other Penalties, or bath, I alsa certify that I have read the detachable information thect. I nuthorize my rchool to diclore to Uhe Social Security ‘Administration any information concerning my status ae student ari pertains to part current, or future Social Security student benefits, ‘SIGNATURE OF STUDENT ‘sian | Pspae dae stl Toot name (Write sn sk) Mailing ores BC alt tate [BOIS 2870 be Cosas Oki} Form SSA.1872-BK (022012) of 022012) Poge 2Form Approved SOCIAL SECURITY ADIMINISTRATION OMB No. 0960.0105, CERTIFICATION BY SCHOOL OFFICIAL Name of Student BNC # DAKOTA J. RIVELLI CORB 22RT996196382, 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 OyYes ONo 2) Is the school’s course of study at least 13 weeks in duration? OyYes No 8) Please indicate which of the following applies to the school’s operating basis. O Yearly CO 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. OYes [No 5) I annotated page 4 of this form with the student's expected graduation date as reported on page 2 of this form. O Yes ONo 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 conce or any other questions you have about Social Security: For more information, please see: www.socialsecurity.gov/ schoolofficials/. Form SSA-1872-BK (022012) ef (022012) Page 3 o89¢T00SCHOOL SHOULD DETACH AND RETAIN THIS FORM SOCIAL SECURITY ADMINISTRATION [Field Office Name and Address SOCIAT. SECURITY 240] W. SHAWNEE STREET MUSKOGER OK 74401-2275 NOTICE OF CESSATION OF FULL-TIME SCHOOL ATTENDANCE Form Approved OMB No. 0960-0105 NAME OF SOCIAL SECURITY BENEFICIARY DAKOTA J. RIVELLI CORB DATE OF BIRTH BNC # 22RT996196382 ‘STUDENTS SOCIAL SECURITY NUMBER ‘STUDENTS EXPECTED GRADUATION DATE (FROM PAGE 2) — (ienth, Year) 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 PARTTIME. stat 1 8. Foiled to continue in fulltime ot T 4 other (explain nance at start of new term (or new school year) NAME AND ADDRESS OF SCHOOL, Tdeclare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements oF SIGNATURE (OR FACSIMILE) OF SCHOOL OFFICIAT. it fe true and correct to the best of my kn PRINTED NAME edge TIE 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 shouid 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.socialsecuril gov) ‘Thank you for your cooperation Form SSA-1872BK (022012) ef (022012) Page 4 69400 Ee