Form Ssa-8-F6 - Application For Lump-Sum Death Payment
ADVERTISEMENT
1
2
3
4TOE 120/145/155
Social Security Administration
Form Approved
OMB No. 0960-0013
APPLICATION FOR LUMP-SUM DEATH PAYMENT*
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-
Age, Survivors, and Disability Insurance) of the Social Security Act, as presently
amended, on the named deceased's Social Security record.
(This application must be filed within 2 years after the date of
death of the wage earner or self-employed person.)
* This may also be considered an application for insurance benefits payable
under the Railroad Retirement Act.
FIRST NAME, MIDDLE INITIAL, LAST NAME
1.
(a) PRINT name of Deceased Wage Earner
or Self-Employed Person
(herein referred to as the "deceased")
Male
Female
(b) Check (X) one for the deceased
/
/
(c) Enter deceased's Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
2.
PRINT your name
3.
Enter date of birth of deceased
(Month, day, year)
4.
(a) Enter date of death
(Month, day, year)
(b) Enter place of death
(City and State)
5.
Yes
No
Unknown
(a) Did the deceased ever file an application for Social Security
benefits, a period of disability under Social Security,
(If "No" or "Unknown,"
(If "Yes," answer
supplemental security income, or hospital or medical
go on to item 6.)
(b) and (c).)
insurance under Medicare?
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name(s) of person(s) on whose
Social Security record(s) other
application was filed.
(c) Enter Social Security Number(s) of person(s) named in (b).
/
/
(If unknown, so indicate)
6.
ANSWER ITEM 6 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.
AMOUNT
(a) About how much did the deceased earn from employment
and self-employment during the year of death?
$
AMOUNT
(b) About how much did the deceased earn the year before
death?
$
ANSWER ITEM 7 ONLY IF THE DECEASED DIED PRIOR TO AGE 66 AND WITHIN THE PAST 4 MONTHS.
7.
Yes
No
(a) Was the deceased unable to work because of illness, injuries
(If "Yes,"
(If "No," go on
or conditions at the time of death?
answer (b).)
to item 8.)
(b) Enter the date the deceased became unable to work
(Month, day, year)
8.
(a) Was the deceased in the active military or naval service
Yes
No
(including Reserve or National Guard active duty or active
(If "Yes," answer
(If "No," go on
duty for training) after September 7, 1939 and before 1968?
(b) and (c).)
to item 9.)
From: (Month, Year)
To: (Month, Year)
(b) Enter dates of service.
(c) Has anyone (including the deceased) received, or does
anyone expect to receive, a benefit from any other
Yes
No
Federal agency?
Did the deceased work in the railroad
9.
Yes
No
industry for 7 years or more?
Page 1
Form SSA-8-F6 (02-2013) EF (02-2013)
Destroy Prior Editions
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal