Form SSA-5-BK Application for Mother's or Father's Insurance Benefits

Form SSA-5-BK Application for Mother's or Father's Insurance Benefits

What Is Form SSA-5-BK?

Form SSA-5-BK, Application for Mother's or Father's Insurance Benefits, is a legal document completed by surviving spouses and surviving divorced spouses of insured wage-earners to qualify for insurance benefits in order to take care of the deceased workers' children and grandchildren.

Alternate Name:

  • Mother or Father Insurance Benefits Application.

This form was released by the Social Security Administration (SSA). The latest version of the form was issued on , with all previous editions obsolete. You can download a fillable SSA-5-BK Form through the link below. Applicants must comply with the following requirements to be eligible for insurance benefits:

  • You are unmarried;
  • You are the widow(er) of the insured worker;
  • Your marriage lasted at least 10 years or ended with the worker's death;
  • You are not entitled to a higher personal retirement or widow's or widower's benefit;
  • You have in your care the deceased's child or dependent grandchild who is under age 16 or older with a disability.
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Form SSA-5-BK Instructions

Follow these steps to complete Form SSA-5-BK:

  1. Enter the full name, gender, and social security number of the deceased wage-earner. Write down your full name, social security number, date, and place of birth.
  2. Identify the deceased's children and dependent grandchildren.
  3. State whether you have ever filed for Social Security benefits, Supplemental Security Income, or Medicare insurance and whether you have been unable to work during the past 14 months due to an illness or injury.
  4. If you have worked in the railroad industry for five years or more or you have Social Security credits in another country, answer "yes".
  5. If the deceased's parents received support from the deceased, check the appropriate box.
  6. Describe your marriage to the deceased and subsequent marriages - spouses' names, dates and places of marriages, how, when, and where they ended. Record who performed the marriages, and spouses' dates of birth and death.
  7. Provide information about the deceased's marriages if they were married after the marriage to you.
  8. State whether you and the deceased shared a household at the time of their death, and if one of you were away from home at the time of death, explain the reason.
  9. Enter the amount of your total earnings last year and the expected amount of earnings this year and next year.
  10. If you qualify or expect to qualify for any government pension or annuity, answer "yes" and check the boxes that apply.
  11. Add the direct deposit payment address to receive the SSA benefits.
  12. Certify the information in the application is true and correct, add your mailing address and telephone, sign and date the form.

SSA-5-BK Related Forms:

Download Form SSA-5-BK Application for Mother's or Father's Insurance Benefits

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