Form Ssa-1724-F4 - Claim For Amounts Due In The Case Of A Deceased Social Security Recipient
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3Form 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
NAME OF THE WORKER
If the deceased received benefits on another person's record, print
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:
1.
NAME OF SURVIVING WIDOW(ER)
ADDRESS OF SURVIVING WIDOW(ER)
(Please print house number,
street, apt. number, P.O. Box, rural route, city, state, and ZIP code)
(Please print. If none, state "NONE")
ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER)
NAMED ABOVE.
If "YES", then
YES
NO
WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE
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
YES
If "YES", then
NO
ON THE SAME EARNINGS RECORD AS THE DECEASED
SKIP items 2,3,4,5 and
(Go on to item 2)
AT THE TIME OF DEATH?
SIGN at bottom of page 2.
2.
NUMBER
ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND
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 (10-2012) Use Prior Editions
Page 1
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