Application For Surviving Disabled Child Insurance Benefit Form
ADVERTISEMENT
1
2Republic of Palau
SOCIAL SECURITY ADMINISTRATION
Date Received/Logged: ________________________
Date Filed/Complete: ________________________
Telephone Number: _______________________
APPLICATION FOR SURVIVOR DISABLED CHILD INSURANCE BENEFITS
I hereby apply for all insurance benefits payable to me under the Social Security Act, as amended.
1.
Child’s Social Security Number
First
Middle
Last
2.
Child’s Full Name
Month
Day
Year
3.
Child’s Date of Birth: _______/____/______
4. Child’s relationship to the deceased _____________________
5.
Applicant’s Full Name: ___________________________ 6. Social Security Number______ ____ _________
7.
Address:
Phone:
Current Residence:
City and State:
Zip Code:
Month
Day
Year
8. Applicant’s Date of Birth______________/_____/________
9. Citizenship:________________________
10. Your relationship to the child: ________________________________________________
11. Did the child live with the deceased at the time of death?
Yes
No
12. Does the child live with you?
Yes
No If No, with whom does the child live?
13. Describe (in detail) the nature of the child’s disability:
14. What month, day and year did you realize the child’s disability condition?
15. I authorize any physician or hospital to disclose to Social Security any medical records or other information about
the child’s disability.
16. Does (did) the child have earnings?
Yes, if yes when ______________ Amount of Earnings $______________
No
17. How your earnings affect your benefits: The child may earn up to $1,800.00 per quarter and still receive all his/her
survivor benefits. If he/she earn over that amount, $1.00 in benefits will be reduced for each $3.00 of earnings
over $1,800.00 per quarter.
SURVIVOR DISABLED CHILD APPLICATION
ROPSSA 630-05(Rev. 01/26/09)
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business