Completing The Claim Form Instruction

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How to Complete the Claim Form
Line 1 – Social Security Number
Enter your Social Security number in the space provided. The number
is required for account identification. (See the Privacy Notification at
the end of this document.)
Line 2 – Claimant’s Name
Print or type your full name in the space provided. Use the pre-
addressed label if there is one.
Line 3 –
Date of Birth
Enter the month, day, and year you were born. For example, if you
were born on July 15, 1935, enter 07/15/1935.
Line 4 – “In Care of” Name
If correspondence is to be sent in care of someone else (such as your
son, daughter, or conservator), enter the person’s name.
Line 5 and 6 – Mailing Address
Enter the mailing address to which all correspondence should be sent.
Do not abbreviate.
Line 7 –
Spouse Information
Enter your spouse’s Social Security number, age, and full name in the
spaces provided. (See the Privacy Notification.)
Lines 8 and 9 – Location of Residential Dwelling
Complete only if the residential address is different from the mailing
address on lines 5 and 6.
Line 10 – Proof of Age
If you will be 62 or older on or before December 31, 2001, whether or
not you are blind or disabled, check the box on line 10. See "Required
Documentation" for acceptable proof of age.
Line 11 – Proof of Blindness or Disability
Blindness
If you are blind but less than 62 years old, check the box on line 11.
See "Required Documentation" for acceptable proof of blindness.

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