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Form Ssa-1724-F4 - Claim For Amounts Due In The Case Of A Deceased Social Security Recipient - 2010 Page 2

If any child listed in Item 2 now has a different name from that given at birth, attach a separate sheet with the following information:

Child's Present Name, Name Given At Birth, and a brief explanation for the difference (e.g. Marriage or Court Order).

ENTER NUMBER OF LIVING PARENTS OF THE DECEASED

NUMBER

(Include adopting parents and stepparents . If none, show "None") IF THERE ARE NO LIVING PARENTS, GO

ON TO ITEM 5.

PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT

NAME OF LIVING PARENT

ADDRESS OF LIVING PARENT (Include house number, street, apt.

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

ENTER SOCIAL SECURITY NUMBER OF PARENT NAMED

___ ___ ___ - ___ ___ - ___ ___ ___ ___

NAME OF LIVING PARENT

ADDRESS OF LIVING PARENT (Include house number, street, apt.

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

ENTER SOCIAL SECURITY NUMBER OF PARENT NAMED.

___ ___ ___ - ___ ___ - ___ ___ ___ ___

LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Skip this item if relatives are listed in 1, 2, or 4.)

NAME OF LEGAL REPRESENTATIVE (Please print)

ADDRESS OF LEGAL REPRESENTATIVE (Please print house

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

code.)

NOTE: If you are applying as legal representative, please submit a certified copy of your letters of appointment.

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

SIGNATURE (First name, middle initial, last name)

DATE (Month, day, year)

TELEPHONE NUMBER

(Include area code)

MAILING ADDRESS (House number and street, apt. number, P.O. Box, or rural route)

CITY

STATE

NAME OF COUNTY

ZIP CODE

Direct Deposit Payment Address (Financial Institution)

Type of Account

Nine Digit Routing Number

__ Checking

__ Savings

___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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.

SIGNATURE OF WITNESS

ADDRESS (House number and street, city, state, and ZIP code)

Form SSA-1724-F4 (01-2010)

Page 2 of 3

Form Ssa-1724-F4 - Claim For Amounts Due In The Case Of A Deceased Social Security Recipient - 2010 Page 2

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