Form SSA-1724-F4 Claim for Amounts Due in the Case of a Deceased Beneficiary

What Is Form SSA-1724-F4?

Form SSA-1724-F4, Claim for Amounts Due in Case of a Deceased Beneficiary is a form used for claiming Social Security payments or Medicare Premium refund that a deceased beneficiary may have been due prior or at the time of death.

The form - also known as the SSA Form 1724-F4 or the Social Security deceased beneficiary form - was issued by the Social Security Administration (SSA). The latest version of the document was released in May 2016 with all previous editions still in use. An SSA-1724-F4 fillable form is available for download and digital filing below or on the SSA official website.

The person who claims payments should be a beneficiary's relative or legal representative of the estate. The SSA uses the information provided in this document to determine if the claimant is eligible to receive the Social Security payments. If you claim these benefits as a legal representative of the deceased person, attach a letter of appointment to your Form SSA-1724-F4.

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Form Approved
Social Security Administration
OMB No. 0960-0101
CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED BENEFICIARY
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 and/or a Medicare Premium refund. 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 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.
YES
NO
WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE
If "YES", then
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
NO
If "YES", then
ON THE SAME EARNINGS RECORD AS THE DECEASED
(Go on to item 2)
SKIP items 2,3,4,5 and
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.)
ADDRESS OF CHILD (Include house number, street, apt. number,
NAME OF CHILD
P.O. Box, rural route, city, state, and ZIP code)
RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)
SOCIAL SECURITY NUMBER OF CHILD
ADDRESS OF CHILD (Include house number, street, apt. number,
NAME OF CHILD
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 (05-2016) Use Prior Editions
Page 1
Form Approved
Social Security Administration
OMB No. 0960-0101
CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED BENEFICIARY
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 and/or a Medicare Premium refund. 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 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.
YES
NO
WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE
If "YES", then
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
NO
If "YES", then
ON THE SAME EARNINGS RECORD AS THE DECEASED
(Go on to item 2)
SKIP items 2,3,4,5 and
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.)
ADDRESS OF CHILD (Include house number, street, apt. number,
NAME OF CHILD
P.O. Box, rural route, city, state, and ZIP code)
RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)
SOCIAL SECURITY NUMBER OF CHILD
ADDRESS OF CHILD (Include house number, street, apt. number,
NAME OF CHILD
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 (05-2016) Use Prior Editions
Page 1
3.
If any child listed in item 2 has a different name from that given at birth, attach a separate sheet with the following information:
Child's Present Name, Name Given At Birth, and a brief explanation for the difference (e.g. Marriage or Court Order).
4.
NUMBER
ENTER NUMBER OF LIVING PARENTS OF THE DECEASED
(Include adopting parents and stepparents. If none, show "None") IF THERE ARE NO LIVING PARENTS, GO
ON TO ITEM 5.
PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT
NAME OF LIVING PARENT
ADDRESS OF LIVING PARENT (Include house number, street, apt.
number, P.O. Box, rural route, city, state, and ZIP code)
ENTER SOCIAL SECURITY NUMBER OF PARENT NAMED
NAME OF LIVING PARENT
ADDRESS OF LIVING PARENT (Include house number, street, apt.
number, P.O. Box, rural route, city, state, and ZIP code)
ENTER SOCIAL SECURITY NUMBER OF PARENT NAMED.
5.
LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Skip this item if relatives are listed in 1, 2, or 4.)
NAME OF LEGAL REPRESENTATIVE (Please print)
ADDRESS OF LEGAL REPRESENTATIVE (Please print house
number, street, apt. number, P.O. Box, rural route, city, state, and
ZIP code.)
NOTE: If you are applying as legal representative, please submit a certified copy of your letters of appointment.
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.
SIGNATURE OF APPLICANT
SIGNATURE (First name, middle initial, last name)
DATE (Month, day, year)
TELEPHONE NUMBER
(Include area code)
MAILING ADDRESS (House number and street, apt. number, P.O. Box, or rural route)
CITY
STATE
NAME OF COUNTY
ZIP CODE
Direct Deposit Payment Address (Financial Institution)
Nine Digit Routing Number
Type of Account
Checking
Savings
Account Number
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.
SIGNATURE OF WITNESS
SIGNATURE OF WITNESS
ADDRESS (House number and street, city, state, and ZIP code)
ADDRESS (House number and street, city, state, and ZIP code)
Form SSA-1724-F4 (05-2016)
Page 2
PRIVACY ACT NOTICE
Section 204(d) of the Social Security Act, as amended, authorizes us to collect this information. We will use this
information to help us determine the beneficiary’s payment.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested information
may prevent us from making an accurate and timely decision on your claim, which may result in the loss of payments.
We rarely use the information you supply for any purpose other than for determining problems in Social Security
programs. However, we may use it for the administration and integrity of Social Security programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses, which include,
but are not limited to the following:
1)
To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration in the efficient administration of its programs;
2)
To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veteran's Affairs);
3)
To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and,
4)
To facilitate statistical research, audit, or investigatory activities necessary to assure the integrity and
improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State, or local government agencies. We use the information from these
matching programs to establish or verify a person's eligibility for federally-funded and administered benefit programs
and for repayment, incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089,
Claims Folder Systems, and 60-0090, Master Beneficiary Record. These notices, additional information regarding our
programs and systems, are available on-line at
www.socialsecurity.gov
or at any local Social Security office.
This information collection meets the requirements of 44 U.S.C. § 3507, as
Paperwork Reduction Act Statement
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Form SSA-1724-F4 (05-2016)
Page 3

Download Form SSA-1724-F4 Claim for Amounts Due in the Case of a Deceased Beneficiary

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Why Did I Receive Form SSA-1724-F4?

If the SSA has some amount due to the beneficiary who is already deceased, they may pay the funds to the closest kin or legal representative of beneficiary's estate. In this case, the SSA will send you the SSA Form 1724-F4 informing about the situation and asking to complete and submit the document to determine whether you or the person you know are eligible to receive the SSA benefits due to the deceased individual.

The benefits may be paid in the following order:

  1. A surviving spouse that lived with the deceased at the time of death or was entitled to receive a monthly benefit on the same record;
  2. Children who were entitled to a monthly payment on the same record for the month of death;
  3. Parents who were entitled to receive a monthly benefit on the same record for the month of death;
  4. A surviving spouse who does not fit the abovementioned criteria;
  5. Children that do not meet the abovementioned requirement;
  6. Parents that do not qualify under item 3;
  7. A legal representative of the estate.

A Medicare Premium refunds are provided to the individuals or organizations who paid the beneficiary's premiums. If the beneficiary was the person who paid the premiums, the refunds are paid to a family member or a legal representative of the estate. In this case, the order of entitlement changes and the legal representative of the deceased person's estate becomes the first person eligible for Medicare Premium refunds.

Form SSA-1724-F4 Instructions

The claim is relatively easy to complete. It will take about 10 minutes to look through the instructions, to find the information, and to answer the required questions. Instructions on filling out Form SSA-1724-F4 can be found below.

How to Fill out Form SSA-1724-F4?

Fill out the form only if it shows valid Office of Management and Budget control number. Providing the requested information is totally voluntarily. However, if you fail to furnish the information you are asked about or provide incomplete data it may result in loss of your payments. Fill out the form as follows:

  1. Indicate the name of the deceased individual;
  2. Specify the SSN of the deceased individual;
  3. If the deceased received Social Security benefits on the record of another person, provide the name of that person;
  4. Specify the deceased beneficiary's date of death;
  5. Specify the deceased beneficiary's state of living;
  6. Provide your name and your relationship to the deceased;
  7. Enter the name of the surviving spouse. If there left none, print "None".
  8. Indicate the full mailing address of the surviving spouse;
  9. Specify the SSN of the surviving spouse;
  10. Specify if the surviving spouse was living in the same household as the deceased and entitled to a monthly benefit on the same earnings record. If you answered "Yes" to any of these questions, skip all the rest and sign the document at the bottom of page 2.
  11. Provide the number of beneficiary's children, including adopted, stepchildren, and grandchildren;
  12. Indicate the name, SSN, and full mailing address of each child, as well as their relation to the deceased beneficiary. If you require more space, attach a separate sheet.
  13. If any of the listed children has a different name from that given at birth, provide the following information on a separate sheet: the present name of a child, the name given at birth, the explanation for the difference;
  14. Specify the number of living parents of the deceased beneficiary, including stepparents and adopting parents. If there are no living parents, enter "None" and move to item 5. Otherwise, enter the name, SSN, and full mailing address of each parent;
  15. If no relatives are indicated in items 1, 2, or 4, provide the name and address of the legal representative of the deceased beneficiary's estate in item 5. Otherwise, skip this part. If you submit this form as the legal representative of the estate, attach the certified copy of your letter of appointment.
  16. Sign the document, provide your first name, middle initial, and last name;
  17. Specify the completion date;
  18. Indicate your contacts, including telephone number and full mailing address;
  19. Provide the account information, including the type of the account and the routing number.

Where to Send Form SSA-1724-F4?

If Form SSA-1724-F4 was mailed to you, place your completed document in the enclosed envelope and mail it back to the sender. If you initiate submitting of this form, take or mail it to the nearest SSA office. You can check up the address you need on the SSA website.

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