Form SSA-5-BK (10-2018) UF
Page 1 of 7
Discontinue Prior Editions
Form Approved
Social Security Administration
TOE 120/145/155
OMB No. 0960-0003
TEL
(Do not write in this space)
APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*
With this application, you are applying for all insurance benefits for which you are 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. The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment.
*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).
FIRST NAME, MIDDLE INITIAL, LAST NAME
1. (a) PRINT name of deceased wage earner or self-employed
person (herein referred to as the "deceased").
(b) Check (X) one for the deceased.
Male
Female
(c) Enter deceased's Social Security Number.
2. (a) PRINT your name.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter your Social Security Number.
3. Enter your name at birth if different from item 2(a).
MONTH, DAY, YEAR
4. (a) Enter your date of birth.
(b) Enter name of State or foreign country where
you were born.
PLEASE READ CAREFULLY BEFORE ANSWERING ITEM 5
You may receive a mother's or a father's benefit for any month in which you have in your care the deceased's child or
dependent grandchild who is entitled to a child's benefit if the child is:
• under age 16,
• or disabled or handicapped (age 16 or over and disability began before age 22).
If you are filing as a surviving divorced mother or father, the child must be your son, daughter, or legally adopted child who
is entitled to child's benefits on the deceased's earnings record.
Mother's or father's benefits are not payable if the only child in your care is a child age 16 or over who is not disabled.
5.
Has an unmarried child or dependent grandchild of the deceased, who is under age 16 or disabled, lived with you any
time from the month of death through the present month? (This includes adopted child, stepchild, and stepgrandchild.)
(If "Yes," enter the information requested below.)
Yes
No
Name of child
Months and Year child lived with you (If all, write "ALL")
Form SSA-5-BK (10-2018) UF
Page 1 of 7
Discontinue Prior Editions
Form Approved
Social Security Administration
TOE 120/145/155
OMB No. 0960-0003
TEL
(Do not write in this space)
APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*
With this application, you are applying for all insurance benefits for which you are 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. The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment.
*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).
FIRST NAME, MIDDLE INITIAL, LAST NAME
1. (a) PRINT name of deceased wage earner or self-employed
person (herein referred to as the "deceased").
(b) Check (X) one for the deceased.
Male
Female
(c) Enter deceased's Social Security Number.
2. (a) PRINT your name.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter your Social Security Number.
3. Enter your name at birth if different from item 2(a).
MONTH, DAY, YEAR
4. (a) Enter your date of birth.
(b) Enter name of State or foreign country where
you were born.
PLEASE READ CAREFULLY BEFORE ANSWERING ITEM 5
You may receive a mother's or a father's benefit for any month in which you have in your care the deceased's child or
dependent grandchild who is entitled to a child's benefit if the child is:
• under age 16,
• or disabled or handicapped (age 16 or over and disability began before age 22).
If you are filing as a surviving divorced mother or father, the child must be your son, daughter, or legally adopted child who
is entitled to child's benefits on the deceased's earnings record.
Mother's or father's benefits are not payable if the only child in your care is a child age 16 or over who is not disabled.
5.
Has an unmarried child or dependent grandchild of the deceased, who is under age 16 or disabled, lived with you any
time from the month of death through the present month? (This includes adopted child, stepchild, and stepgrandchild.)
(If "Yes," enter the information requested below.)
Yes
No
Name of child
Months and Year child lived with you (If all, write "ALL")
Form SSA-5-BK (10-2018) UF
Page 2 of 7
6.
(a) Have you (or has someone on your behalf) ever filed an application for
Yes
No
Social Security benefits, a period of disability under Social Security,
(If "Yes," answer
(If "No," go on to
Supplemental Security Income, or hospital or medical insurance under
(b) and (c).)
item 7.)
Medicare?
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name of person(s) on whose Social Security record
you filed other application.
(c) Enter Social Security Number of person named in (b).
(If unknown, so indicate.)
7. (a) Are you, or during the past 14 months have you been, unable to work
Yes
No
because of illnesses, injuries or conditions?
(If "Yes,"
(If "No," go on
answer (b).)
to item 8.)
MONTH, DAY, YEAR
(b) Enter the date you became unable to work.
8. Did you work in the railroad industry for 5 years or more?
Yes
No
9. (a) Do you have Social Security credits (for example, based on work or
Yes
No
residence) under another country's Social Security system?
(If "Yes,"
(If "No," go on
answer (b).)
to item 10.)
(b) If "Yes," list the country(ies).
10.
Is there a surviving parent (or parents) of the deceased who was receiving
Yes
No
support from the deceased at the time of death or at the time the deceased
(If "Yes," enter the name and address of
became disabled?
the parent(s) in "Remarks" on page 5.)
11.
INFORMATION ON YOUR MARRIAGE(S)
(a) Enter information about your marriage to the deceased.
Spouse's Name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, Year)
Where (Name of City and State)
Marriage performed by:
Spouse's date of birth (or age)
Date of death
Clergyman or public official
Other (Explain in "Remarks")
(b) If you remarried after the marriage shown in 11. (a), enter information about the last marriage.
(If none, write "NONE".)
Spouse's Name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, Year)
Where (Name of City and State)
Marriage performed by:
Spouse's date of birth (or age)
If spouse deceased, give date of death
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
(c) If you had other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether
before or after you married the deceased), enter the information below. If you divorced then remarried the same
individual within the year immediately following the year of the divorce, and the combined period of marriage totaled
10 years or more, include the marriage. (If none, write "NONE".)
Form SSA-5-BK (10-2018) UF
Page 3 of 7
Spouse's Name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, Year)
Where (Name of City and State)
Spouse's date of birth (or age)
If spouse deceased, give date of death
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
12.
INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)
Answer this item ONLY if the deceased had other marriages.
(a) If the deceased married after his or her marriage to you, enter the information on the last marriage.
(If none, write "NONE".)
Spouse's Name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, Year)
Where (Name of City and State)
Marriage performed by:
Spouse's date of birth (or age)
If spouse deceased, give date of death
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
(b) Enter information about any other marriage the deceased may have had that lasted at least 10 years (see item
11. (c) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse
(whether before or after you married the deceased). Do not include the marriage to you.
(If none, write "NONE".)
Spouse's Name (including maiden name)
When (Month, Day, Year)
Where (Name of City and State)
How Marriage Ended
When (Month, Day, Year)
Where (Name of City and State)
Spouse's date of birth (or age)
Date of death
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, SKIP ITEM 13 AND GO ON TO ITEM 14.
13. (a) Were you and the deceased living together at the same address when the
No
Yes
deceased died?
(If "Yes," skip to
(If "No,"
item 14.)
answer (b).)
(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died,
give the following:
Who was away?
You
Deceased
Reason absence began
Date last at home
Form SSA-5-BK (10-2018) UF
Page 4 of 7
Reason you were apart at time of death
If separated because of illness, enter nature of illness or
disabling condition
ANSWER ITEM 14 ONLY IF THE DECEASED DIED BEFORE THIS YEAR. OTHERWISE, GO ON TO ITEM 15.
(a) How much were your total earnings last year? $
14.
(b) Place an "X" in each block for EACH MONTH of last year in which you did not
NONE
ALL
earn more than *$
in wages, and did not perform substantial services
in self-employment. These months are exempt months. If no months were exempt
JAN
FEB
MAR
APR
months, place an "X" in "NONE". If all months were exempt months, place an "X"
in "ALL."
MAY
JUN
JUL
AUG
*Enter the appropriate monthly limit after reading the instructions, "How Your
SEPT
OCT
NOV
DEC
Earnings Affect Your Benefits".
15. (a) How much do you expect your total earnings to be this year? $
(b) Place an "X" in each block for EACH MONTH of this year in which you did not or
NONE
ALL
will not earn more than *$
in wages, and did not or will not perform
substantial services in self-employment. These months are exempt months. If no
JAN
FEB
MAR
APR
months are or will be exempt months, place an "X" in "NONE". If all months are or
will be exempt months, place an "X" in "ALL".
MAY
JUN
JUL
AUG
*Enter the appropriate monthly limit after reading the instructions, "How Your
SEPT
OCT
NOV
DEC
Earnings Affect Your Benefits".
ANSWER ITEM 16 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT., OCT., NOV.,
AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR). OTHERWISE, GO ON TO ITEM 17.
(a) How much do you expect to earn next year? $
16.
NONE
ALL
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
expect to earn more than *$
in wages, and do not expect to perform
substantial services in self-employment. These months will be exempt months. If
JAN
FEB
MAR
APR
no months are expected to be exempt months, place an "X" in "NONE". If all
months are expected to be exempt months, place an "X" in "ALL".
MAY
JUN
JUL
AUG
*Enter the appropriate monthly limit after reading the instructions, "How Your
SEPT
OCT
NOV
DEC
Earnings Affect Your Benefits".
MONTH
If you use a fiscal year, that is, a taxable year that does not end December 31
(with income tax return due April 15), enter here the month your fiscal year ends.
No
Yes
17. (a) Have you qualified for, or do you expect to qualify for, a pension or
annuity (or a lump sum in place of a pension or annuity) based on
(If "Yes," check
(If "No," go on, to
your own employment and earnings for the Federal Government of
the box in item (b)
item 18.)
the United States, or one of its States or local subdivisions? (Social
that applies.)
Security benefits are not government pensions).
I have not applied for but I expect to
(b)
I receive a government pension or annuity.
begin receiving my pension or
annuity: (If the date is not known,
I received a lump sum in place of a government pension
enter "Unknown.")
or annuity.
Month
Year
I applied for and am awaiting a decision on my pension or lump sum.
18.
Check if applicable:
I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand
that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid
with full retroactivity.
(Turn to Page 5)
Form SSA-5-BK (10-2018) UF
Page 5 of 7
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
Direct Deposit Payment Address (Financial Institution)
Routing Transit Number
Account Number
Checking
Enroll in Direct Express
Savings
Direct Deposit Refused
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. I understand that anyone who
knowingly gives a false statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be subject to a fine or imprisonment.
Date (Month, Day, Year)
SIGNATURE OF APPLICANT
Telephone number(s) at which you may be
Signature (First Name, Middle Initial, Last Name) (Write in ink)
contacted during the day
SIGN
AREA CODE
HERE
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks" on page 5, if different.)
City and State
ZIP Code
County (if any) in which you now live
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. Also, print the
applicant's name in the Signature block.
1. Signature of Witness
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
Address (Number and Street, City, State and ZIP Code)
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