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Form Approved

Social Security Administration

OMB No. 0960-0101

CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED SOCIAL SECURITY RECIPIENT

PRINT NAME OF DECEASED

SOCIAL SECURITY NUMBER OF DECEASED

___ ___ ___ - ___ ___ - ___ ___ ___ ___

If the deceased received benefits on another person's record, print

NAME OF THE WORKER

name of that worker

The deceased may have been due a Social Security payment at the time of death. The Social Security Act provides that amounts

due a deceased may be paid to the next of kin or the legal representative of the estate under priorities established in the law.

To help us decide who should receive any payment due, please COMPLETE THIS ENTIRE FORM and RETURN it to us in the

enclosed envelope.

This claim for the amounts due from the Social Security Administration is being made on behalf of the family or the estate of

_________________________ who died on ______________ day of ________________

_________________

(name of deceased)

(month)

(year)

and who lived in the state of _________________________ .

PRINT NAME OF APPLICANT

RELATIONSHIP TO DECEASED (Widow, Son, Legal Representative,

etc.)

THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVE OF THE DECEASED NAMED ABOVE:

NAME OF SURVIVING WIDOW(ER)

ADDRESS OF SURVIVING WIDOW(ER)

(Please print house number,

(Please print. If none, state "NONE")

street, apt. number, P.O. Box, rural route, city, state, and ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER)

NAMED ABOVE.

___ ___ ___ - ___ ___ - ___ ___ ___ ___

WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE

YES

If "YES", then

SAME HOUSEHOLD WITH THE DECEASED AT THE TIME

SKIP items 2,3,4,5 and

OF DEATH?

SIGN at bottom of page 2.

WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT ON

YES

If "YES", then

THE SAME EARNINGS RECORD AS THE DECEASED AT

SKIP items 2,3,4,5 and

(Go on to item 2)

THE TIME OF DEATH?

SIGN at bottom of page 2.

ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND

NUMBER

STEPCHILDREN; INCLUDE GRANDCHILDREN AND STEP-GRANDCHILDREN IF THEIR PARENTS ARE

DISABLED OR DECEASED; OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF THE

DECEASED. IF NONE OF THE ABOVE, SHOW "NONE" AND GO ON TO ITEM 4.

PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD

Remarks -(If you need more space for explaining any answers to the questions, attach a separate sheet.)

NAME OF CHILD

ADDRESS OF CHILD (Include house number, street, apt. number,

P.O. Box, rural route, city, state, and ZIP code)

RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)

SOCIAL SECURITY NUMBER OF CHILD

___ ___ ___ - ___ ___ - ___ ___ ___ ___

NAME OF CHILD

ADDRESS OF CHILD (Include house number, street, apt. number,

P.O. Box, rural route, city, state, and ZIP code)

RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)

SOCIAL SECURITY NUMBER OF CHILD

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Form SSA-1724-F4 (01-2010) EF (01-2010) Destroy Prior Editions

Page 1 of 3

Form Ssa-1724-F4 - Claim For Amounts Due In The Case Of A Deceased Social Security Recipient

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