Form Ssa-8-F4 - Application For Lump-Sum Death Payment Page 2
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1
2
3
4Did the deceased ever engage in work that was covered
(a)
10.
under the social security system of a country other than the
Yes
No
United States?
(If "Yes," answer (b).) (If "No," go on to item 11.)
(b)
If "Yes," list the country(ies).
Is the deceased survived by a spouse or ex-spouse? (If "No," go on to item 12. If "Yes,"
11.
give the following information about all marriages of the deceased including marriage in
Yes
No
effect at time of death.) (If you need more space, use "Remarks" section on back page
or attach a separate sheet.)
To whom married (Name at Birth)
When (Month, day, year)
Where (Enter name of City and State)
Where (Enter name of City and State)
How marriage ended
When (Month, day, year)
Last
Spouse's date of birth (or age)
If spouse deceased, give date of death
Marriage performed by:
marriage
Clergyman or public official
of the
Other (Explain in Remarks)
deceased
/
/
Spouse's Social Security Number (If none or unknown, so indicate)
When (Month, day, year)
To whom married (Name at Birth)
Where (Enter name of City and State)
Where (Enter name of City and State)
How marriage ended
When (Month, day, year)
Previous
marriage
Spouse's date of birth (or age)
If spouse deceased, give date of death
Marriage performed by:
of the
Clergyman or public official
deceased
Other (Explain in Remarks)
If none
write "None."
/
/
Spouse's Social Security Number (If none or unknown, so indicate)
12.
The deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent
grandchildren (including stepgrandchildren) may be eligible for benefits based on the earnings record of the
deceased.
List below ALL such children who are now or were in the past 12 months UNMARRIED and:
• UNDER AGE 18
• AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
(If none, write ''None.'')
Full Name of Child
Full Name of Child
Is there a surviving parent (or parents) of the deceased who was
13.
Yes
No
receiving support from the deceased either at the time the
deceased became disabled under the Social Security law or at the
(If "Yes," enter the name and address of the
time of death?
parent(s) in "Remarks".)
Have you filed for any Social Security benefits on the deceased's
14.
Yes
No
earnings record before?
NOTE: If there is a surviving spouse, continue with item 15. If not, skip items 15 through 18.
If you are not the surviving spouse, enter the surviving spouse's name and address here
15.
(a)
16.
Were the deceased and the surviving spouse living together
No
Yes
at the same address when the deceased died?
(If "Yes," go on to item 17.) (If "No," answer (b).)
(b)
If either the deceased or surviving spouse was away from home (whether or not temporarily) when the deceased
died, give the following:
Who was away?
Deceased
Surviving spouse
Date last home
Reason absence began
Reason they were apart at time of death
If separated because of illness, enter nature
of illness or disabling condition.
Form SSA-8-F4
0009 (5-2003) EF (12-2007)
Page 2
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