Form Ssa-1724 - Claim For Amounts Due In The Case Of Deceased Beneficiary (Page 2 of 2) in pdf

IF ANY CHILD LISTED IN ITEM 2 NOW HAS A NAME DIFFERENT FROM THAT GIVEN AT BIRTH, PRINT BELOW

THAT CHILD'S NAME, THE NAME GIVEN AT BIRTH, AND A BRIEF EXPLANATION FOR THE DIFFERENCE.

CHILD'S PRESENT NAME

CHILD'S NAME AT BIRTH

EXPLANATION

(Marriage, court order, adoption)

ENTER NUMBER OF LIVING PARENTS OF THE DECEASED

(Include adopting parents and stepparents. If

NUMBER

none, show "None".)

IF THERE ARE NO LIVING PARENTS, GO ON TO ITEM 5.

PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT

ADDRESS OF LIVING PARENT

NAME OF LIVING PARENT

(Include house number,

street, apt. number, P.O. box, rural route, city, state, and

ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF PARENT

NAMED.

(If unknown, indicate "UNKNOWN".)

ADDRESS OF LIVING PARENT

NAME OF LIVING PARENT

(Include house number,

street, apt. number, P.O. box, rural route, city, state, and

ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF PARENT

NAMED.

(If unknown, indicate "UNKNOWN".)

LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Omit this item if relatives are listed in 1, 2, or 4)

ADDRESS OF LEGAL REPRESENTATIVE

(Please print

NAME OF LEGAL REPRESENTATIVE

(Please print)

house number, street, apt. number, P.O. box, rural route,

city, state, and ZIP code)

Note: If you are applying as legal representative, please submit a certified copy of your letters of appointment.

REMARKS: (If you need more space for explaining any answers to the questions, attach a separate sheet.)

COMPUTER MATCHING STATEMENT: We may also use the information you give us when we match records by computer. Matching programs compare our

records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for

benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

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 more about this, contact any Social Security Office.

PAPERWORK REDUCTION ACT: This information collection meets the clearance 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 you about 10 minutes to read the instructions, gather the necessary facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR

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 OF APPLICANT

SIGNATUR

DATE

TELEPHONE NUMBER

E (First name, middle initial, last name)

(Month, day, year)

(Include area code)

MAILING ADDRESS (House number and street, apt. number, P.O. box, or rural route)

CITY

STATE