Form Ssa-8-F4 - Application For Lump-Sum Death Payment Page 3
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4If you are the surviving spouse, and If you are under age 66, answer 17.
(a) Are you so disabled that you cannot work or was there some
17.
period during the last 14 months when you were so disabled
Yes
No
that you could not work?
(Month, day, year)
(b) If ''Yes,'' enter the date you became disabled.
Answer 18 ONLY if you are the surviving spouse.
Were you married before your marriage to the deceased?
18.
(If ''Yes,'' give the following about each of your previous
marriages. If you need more space, use "Remarks" section on
Yes
No
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)
Marriage performed by:
Your
Spouse's date of birth (or age)
If spouse deceased, give date of death
previous
Clergyman or public official
Other (Explain in Remarks)
marriage
/
/
Spouse's Social Security Number (If none or unknown, so indicate)
Remarks: (You may use this space for any explanation. If you need more space, attach a separate sheet.)
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
Date (Month, day, year)
Signature (First name, middle initial, last name) (Write in ink)
Telephone Number(s) at Which You May Be
Contacted During the Day
(Area Code)
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State
Enter Name of County (if any) in which you now live
ZIP Code
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
2. Signature of Witness
1. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
Address (Number and street, City, State, and ZIP Code)
Form SSA-8-F4 0009 (5-2003) EF (12-2007)
Page 3
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