Application For Surviving Disabled Child Insurance Benefit Form Page 2
ADVERTISEMENT
1
2DECEASED WAGE EARNER (question 18 to 26)
18. Social Security Number:
First
Middle
Last
19. Full Name:
Month
Day
Year
20. Sex: Male __ Female __ 21. Date of Birth _______/____/________ 22. Citizenship:__________________
Month
Day
Year
23. Date of Death ______/______/_______
24. Place of Death
25. Cause of Death
(a) Primary:
(b) Secondary:
26. Was the deceased wage earner ever entitled to Social Security Benefits?
Yes
No
27. If yes, what kind of benefits?
Disability
Retirement
28. I understand that all payments made to me on behalf of a child must be spent for the child’s present needs, or, if not
presently needed, saved for the child’s future needs, and I do agree to use the benefits that way.
29. I agree to notify Social Security promptly if any of the following occur and to promptly return any benefit
check I receive which is not due:
a. A Child is adopted or there is a change in custody/Guardianship
b. A disabled child’s condition improves
c. A child goes to work, gets married, or dies
d. Change of Address
e. Change of Child’s Citizenship
Signature: I know that anyone who makes or causes to be made a false statement or representation of material fact in
an application for use in determining a right to payment under the Social Security Act commits a crime punishable by
fine, imprisonment or both. I acknowledge my agreement to the statements in No. 15, No.28 & No.29 and affirm that all
information I have given in this document and any attachments are true and correct.
SIGN HERE: _______________________________________ ______
DATE: _____________________________
).
(Note: This application must be notarized if not signed in the presence of a Social Security Administration Representative
If checked, please provide
Direct Deposit: If you want your payments sent directly to the bank, check here:
c
a
opy of your bank account
Your Bank’s Name & Address ________________________________________ or a bank statement.
Your Bank’s ABA Number___________________________________________
Your Bank’s Account Number______________________________________ Account Type: _______________
Witness:
Required ONLY if this application has been signed by (X). Two witnesses to the signing who know the
applicant must sign below, giving their full address.
Sign Here: _____________________________
Sign Here: __________________________
(
Print Name and Sign)
(Print Name and Sign)
Address: ______________________________
Address: ___________________________
______________________________
___________________________
Note: This application will not be processed without the following documents:
1.
Death Certificate of Wage Earner
2.
Birth Certificate of Child
3.
Applicant Picture Identification
4.
Proof for child dependency if not the natural child or not adopted through Court.
5.
Proof of Guardianship if the applicant is living with someone other than the surviving spouse
of the decedent.
SURVIVOR DISABLED CHILD APPLICATION
2
ROPSSA 630-05(Rev. 01/26/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business