Form Ssa-7-F6 - Application For Parent'S Insurance Benefits
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6Form Approved
TEL
OMB No 0960-0012
Social Security Administration
TOE 120/145/155
(Do not write in this space)
APPLICATION FOR PARENT'S INSURANCE BENEFITS*
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the
Aged and Disabled) of the Social Security Act, as presently amended.
*This may also be considered an application for survivors benefits under the Railroad Retirement Act and
for Veterans Administration payments under Title 38 U.S.C, Veterans Benefits, Chapter 13 (which is, as
such, an application for other types of death benefits under Title 38.) For additional information about this
application a factsheet to Form SSA-7 is available at
1.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT name of deceased wage earner or self-
employed person (herein referred to as the
"Deceased.")
u
(b)
Male
Female
Check (X) one for the Deceased.
u
(c)
/
/
Enter Deceased's Social Security number.
u
FIRST NAME, MIDDLE INITIAL, LAST NAME
2.
(a)
PRINT your name.
u
(b)
/
/
Enter your Social Security number.
u
(c)
Enter your name at birth if different from item 2
(a).
u
Were you receiving at least one-half of your support from the
Yes
No
3.
(a)
Deceased at the time the Deceased became disabled under the
(If "Yes,"
(If "No," go on
Social Security law or at the time of death?
answer (b).)
to item 4.)
u
(b)
Have you filed proof of this support with the Social Security
Yes
No
Administration?
u
PART I -- INFORMATION ABOUT THE DECEASED
4.
MONTH, DAY, YEAR
Enter date of birth of Deceased.
u
MONTH, DAY, YEAR
5.
(a)
Enter date of death.
u
(b)
CITY AND STATE
Enter place of death.
u
6.
(a)
Yes
No
Unknown
Did the Deceased ever file an application for Social Security
benefits, a period of disability under Social Security, Supplemental
(If "Yes," answer
(If "No" or "Unknown" go
Security Income, or hospital or medical insurance under Medicare?
(b) and (c).)
on to item 7.)
u
(b)
FIRST NAME, MIDDLE INITIAL, LAST NAME
Enter name of person on whose Social Security
record other application was filed.
u
(c)
Enter Social Security number of person named in (b), (If
/
/
"Unknown," so indicate.)
u
Answer Item 7 ONLY if the Deceased Died Prior to Full Retirement Age or Prior to One Year Past Full Retirement Age, and
Within the Past 4 Months.
Yes
No
7.
(a)
Was the Deceased unable to work because of a disabling condition at
(If "Yes,"
(If "No," go on
the time of death?
u
answer (b).)
to item 8.)
(b)
MONTH, DAY, YEAR
Enter date disability began.
u
(Over)
Form SSA-7-F6 (06-2016) UF (06-2016) Destroy Prior Editions
Page 1
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