Form Ssa-721 - Statement Of Death By Funeral Director Template
Download a blank fillable Form Ssa-721 - Statement Of Death By Funeral Director Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ssa-721 - Statement Of Death By Funeral Director Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Print Form
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0142
STATEMENT OF DEATH BY FUNERAL DIRECTOR
NAME OF DECEASED
SOCIAL SECURITY NUMBER
-
-
FOR SSA USE ONLY
Please complete the items below and return the
form in the enclosed addressed, postage paid
envelope. Your assistance and cooperation are
appreciated.
PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the Federal
Regulations (20 CFR 404.715 AND 404.720). While your response is voluntary, we need your assistance to make an accurate and timely
determination concerning the death of the individual named above, and to determine if there are survivors who may be eligible for Social Security
benefits.
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 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 3.5 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments or our time estimate above to: SSA, 1338
Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
1. NAME OF DECEASED
2. SOCIAL SECURITY NUMBER
-
-
3. DATE OF DEATH
4. DATE OF BIRTH (if known)
5. CHECK(x) whether the deceased was
Male
Female
6. NAME OF WIDOW OR WIDOWER (if known)
7. ADDRESS (No. and Street, P.O. Box) OF WIDOW OR WIDOWER (if known)
CITY
STATE
ZIP CODE
TELEPHONE NUMBER (if Available)
(
)
-
-
CA
area code
I hereby certify that I am an authorized funeral director and prepared for final disposition the body of the person named above. I understand
this statement may be used in connection with an application for Social Security benefits. 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. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
NAME AND ADDRESS OF FUNERAL DIRECTOR OR FIRM
SIGNATURE OF FUNERAL DIRECTOR OR AUTHORIZED
REPRESENTATIVE
TELEPHONE NUMBER
DATE
(
)
-
area code
FOR SOCIAL SECURITY USE ONLY – DO NOT WRITE IN THIS SPACE
DO Processed (Date)
Form SSA-721 (5-2005) ef (5-2006) Use 1-2004 edition until supply is exhausted
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dl-16lc - Acknowledgment Of Suspension / Revocation / Disqualification / Cancellation Template
Legal
Form Profit Corporation Articles Of Dissolution By Incorporators Or Initial Directors - Wyoming Secretary Of State - 2015
Legal
Form B-06 - Articles Of Dissolution By Board Of Directors And Shareholders Business Corporation
Legal
Form Cf:0028 - Articles Of Dissolution By Incorporators Or Initial Directors - Arizona Secretary Of State - 2005
Legal
Related Categories
Parent category: Legal