Form SSA-4-BK "Application for Child's Insurance Benefits"

What Is Form SSA-4-BK?

Form SSA-4-BK, Application for Child's Insurance Benefits, is a form that is used to apply for Child's Insurance Benefits on behalf of children.

Alternate Name:

    • Child Insurance Benefits Application.

This form was released by the Social Security Administration (SSA) and the latest version was issued on January 1, 2017. A fillable Child Insurance Benefits Application is available for download below.

A child is eligible to get these benefits if they have:

  • A disabled or retired parent, entitled to Social Security benefits; or
  • A deceased parent who has died after paying enough Social Security taxes.

Child Insurance Benefits can be applied for on behalf of the applicant's natural children, their stepchild, grandchild, step-grandchild, and adopted child. The SSA-4-BK Form can be completed by a parent of a child or on behalf of a deceased parent.

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Form SSA-4-BK Instructions

To qualify for Child's Insurance Benefits a child should be unmarried and meet the following conditions:

  • Be younger than 18;
  • Be 18-19 years old and a full-time student (no higher than grade 12); or
  • Be 18 or older and disabled. Their disability, in this case, must have begun before age 22.

Form SSA-4-BK instructions are as follows:

  1. 1 - 2. Enter full names and Social Security numbers of the SSA worker and the eligible applicant.
  2. Part 1 - Information about the worker's children:
    • 3 - 5. Provide information about the children who are eligible for Benefits;
    • 6 - 7. Indicate if you are the natural or adoptive parent of the indicated children, provide information about the presence of any other adoptive parents;
    • 8. Indicate the children are not living with them now;
    • 9. Indicate if any child in Item 3 has ever been married;
    • 10. Provide information about anyone who has ever filed for Benefits on behalf of these children;
    • 11 - 13. Enter the amount of each child's current and expected earnings over the exempt amount for this year, last year and next year;
    • 14. Indicate the name of a child who uses a fiscal year (one that does not end on December 31);
    • 15. Provide information about any children in Item 3 adopted by the worker;
    • 16. Indicate any child who did not live with them during the last 13 months;
    • 17. Respond regarding filing for Supplemental Security Income.
  3. Part 2 - Information about the deceased. Complete items 18 through 26 regarding the deceased worker only.
    • 18 - 24. Provide information about this person;
    • 25. Indicate the earnings of the deceased in the year of death and the year before death;
    • 26. If there are any earnings of the deceased worker that are not yet on their earning records, indicate it in this Item;
    • 27. Indicate if the worker has ever filed for Social Security benefits;
    • 28. Note if the person was unable to work because of a disabling condition;
    • 29. Provide information about any children of the deceased not living with them at the time of death.
  4. Sign the form, enter your full name and phone number.
  5. Provide Direct Deposit Payment information.

Looking to learn more? Check out these related forms and templates:

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Download Form SSA-4-BK "Application for Child's Insurance Benefits"

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Form SSA-4-BK (01-2017) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
TEL
OMB No. 0960-0010
(Do not write in this space)
APPLICATION FOR CHILD'S INSURANCE BENEFITS
With this application, you are applying on behalf of the child or children listed in item 3 below for all
insurance benefits for which they may be eligible under Title II (Federal Old-Age, Survivors and
Disability Insurance) of the Social Security Act as presently amended. If you are applying on your own
behalf, answer the questions on this form with respect to yourself.
If you are applying for benefits based on the earnings record of a Deceased Worker, 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
Life
Death
application for other types of death benefits under Title 38).
Claim
Claim
1.
(a) PRINT name of Wage Earner or Self-Employed person
FIRST NAME, MIDDLE INITIAL, LAST NAME
(herein referred to as the ''Worker'').
(b) PRINT Worker's Social Security number.
2.
(a) PRINT your name (unless you are the Worker).
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) PRINT your Social Security number.
PART 1 - INFORMATION ABOUT THE WORKER'S CHILDREN
3.
The Worker's children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including
step grandchildren) may be eligible for benefits based on the earnings record of the Worker. For a living Worker, the
information below applies to this month or to any of the past 12 months. For a deceased Worker, the information below
applies to the date of death or for any period since the Worker's death.
Check
Check (X) the
List below all children who are:
Check
(X) if
Column That
(X)
Child
Shows Child's
Sex of
17.5 or
Relationship to
• Under age 18
Child
Date of Birth
CHILD'S SOCIAL
Older is:
Worker
• Age 18 to 19 and attending elementary
(Mo., day, yr.)
SECURITY NUMBER
or secondary school full-time
• Disabled or Handicapped (age 18 or
over and disability began before
age 22)
M
F
FULL NAME OF CHILD
If you do not wish to be payee for any child or dependent grandchild named above, list the child's name and address in
"Remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits.
4.
If any children in item 3 are stepchildren of the Worker, enter the
MONTH, DAY, YEAR
date the Worker married the natural parent.
5.
(a) Is there a legal representative (guardian, conservator, curator,
Yes
No
etc.) for any of the children in item 3?
(If "Yes," complete
(If "No," go on to
(b) and (c).)
item 6.)
Form SSA-4-BK (01-2017) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
TEL
OMB No. 0960-0010
(Do not write in this space)
APPLICATION FOR CHILD'S INSURANCE BENEFITS
With this application, you are applying on behalf of the child or children listed in item 3 below for all
insurance benefits for which they may be eligible under Title II (Federal Old-Age, Survivors and
Disability Insurance) of the Social Security Act as presently amended. If you are applying on your own
behalf, answer the questions on this form with respect to yourself.
If you are applying for benefits based on the earnings record of a Deceased Worker, 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
Life
Death
application for other types of death benefits under Title 38).
Claim
Claim
1.
(a) PRINT name of Wage Earner or Self-Employed person
FIRST NAME, MIDDLE INITIAL, LAST NAME
(herein referred to as the ''Worker'').
(b) PRINT Worker's Social Security number.
2.
(a) PRINT your name (unless you are the Worker).
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) PRINT your Social Security number.
PART 1 - INFORMATION ABOUT THE WORKER'S CHILDREN
3.
The Worker's children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including
step grandchildren) may be eligible for benefits based on the earnings record of the Worker. For a living Worker, the
information below applies to this month or to any of the past 12 months. For a deceased Worker, the information below
applies to the date of death or for any period since the Worker's death.
Check
Check (X) the
List below all children who are:
Check
(X) if
Column That
(X)
Child
Shows Child's
Sex of
17.5 or
Relationship to
• Under age 18
Child
Date of Birth
CHILD'S SOCIAL
Older is:
Worker
• Age 18 to 19 and attending elementary
(Mo., day, yr.)
SECURITY NUMBER
or secondary school full-time
• Disabled or Handicapped (age 18 or
over and disability began before
age 22)
M
F
FULL NAME OF CHILD
If you do not wish to be payee for any child or dependent grandchild named above, list the child's name and address in
"Remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits.
4.
If any children in item 3 are stepchildren of the Worker, enter the
MONTH, DAY, YEAR
date the Worker married the natural parent.
5.
(a) Is there a legal representative (guardian, conservator, curator,
Yes
No
etc.) for any of the children in item 3?
(If "Yes," complete
(If "No," go on to
(b) and (c).)
item 6.)
Form SSA-4-BK (01-2017) UF
Page 2 of 9
5.
NAME (First name, middle initial, last name)
TELEPHONE NUMBER
(b) Write the
following information
(INCLUDE AREA CODE)
about the legal
ADDRESS
representative(s):
(c) Briefly explain the circumstances which led the court to appoint a legal representative.
6.
Are you the natural or adoptive parent of the person(s) for whom you
Yes
No
are filing?
7.
Have any children in item 3 ever been adopted by someone other than
Yes
No
the Worker? (If "Yes," enter the following information):
Name of Child
Date of Adoption
Name of Person Adopting
Are all the children in item 3 now living in the same household with
8.
you? (If "No," enter the following information about each child not living
Yes
No
with you. If uncertain as to the whereabouts of any of these children,
explain in "Remarks".)
Name of Child Not Living
Person With Whom Child Now Lives
With You
Name and Address
Relationship to Child
9.
Has any child in item 3 ever been married?
Yes
No
(If "Yes," enter the information requested below.)
Name of Child
Date of Marriage (Month, day, year)
How Marriage Ended (If still married, write "not ended").
Date Marriage Ended (Month, day, year)
10.
Has anyone ever before filed an application with the Social Security
Administration for monthly benefits on behalf of any child in item 3? (If
"Yes," enter below the name(s) of the child(ren) and the name(s) and
Yes
No
Social Security number(s) of the person(s) on whose earnings record
any other claim was based.)
Name of Child
Name of Worker
Social Security Number of Worker
Form SSA-4-BK (01-2017) UF
Page 3 of 9
If you are applying ONLY for a child age 18 or over who is disabled, omit items 11 through 14. In all other cases, answer
items 11 through 14.
EARNINGS INFORMATION FOR LAST YEAR (Do not complete if the Worker died this year)
11.
(a) Did any child in item 3 earn more than the exempt amount last year?
Yes
No
(If "Yes," answer (b). If "No," go on to item 12.)
(b)
NAME OF CHILD WHO
LIST EACH MONTH THAT CHILD DID NOT EARN MORE
TOTAL EARNINGS
EARNED OVER THE EXEMPT
THAN $
IN WAGES AND DID NOT PERFORM
OF CHILD
AMOUNT LAST YEAR
SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT
$
$
$
EARNINGS INFORMATION FOR THIS YEAR
12.
(a) Do you expect the total earnings of any child in item 3 to be more than
the exempt amount this year? (Count all earnings beginning with the
Yes
No
first of this year and all anticipated earnings through the end of this year.)
(If "Yes," answer (b). If "No," go on to item 13.)
LIST EACH MONTH (INCLUDING THE PRESENT MONTH)
(b)
NAME OF CHILD WHO
EXPECTED
THAT CHILD DID NOT OR WILL NOT EARN MORE THAN
EXPECTS TO EARN OVER THE
EARNINGS OF
$
IN WAGES AND DID NOT OR WILL NOT
EXEMPT AMOUNT THIS YEAR
CHILD
PERFORM SUBSTANTIAL SERVICES IN
SELF-EMPLOYMENT
$
$
$
Complete item 13 ONLY if any child is now in the last 4 months of the child's taxable year (Sept., Oct., Nov., and Dec., if
the taxable year is a calendar year).
EARNINGS INFORMATION FOR NEXT YEAR
(a) Do you expect the total earnings of any child in item 3 to be more
13.
than the exempt amount next year? (If "Yes," answer (b.) If "No," go
Yes
No
on to item 14.)
(b)
NAME OF CHILD WHO
EXPECTED
LIST EACH MONTH THAT CHILD WILL NOT EARN MORE
EXPECTS TO EARN OVER THE
EARNINGS OF
THAN $
IN WAGES AND WILL NOT PERFORM
EXEMPT AMOUNT NEXT YEAR
CHILD
SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT
$
$
$
Name of child and month fiscal year ends
14.
If any of the children for whom you are filing uses a fiscal year (one that
does not end on December 31), print here the name of the child and the
month the fiscal year ends.
Complete items 15 and 16 ONLY if the Worker is living. Otherwise, go on to item 17.
15.
If any children in item 3 are children adopted by the Worker, print below the name of each such child and the date of
adoption by the Worker.
NAME OF ADOPTED CHILD
DATE OF ADOPTION
Form SSA-4-BK (01-2017) UF
Page 4 of 9
16.
Have all of the children in item 3 lived with the Worker during each of
the last 13 months (counting the present month)?
Yes
No
(If "No," enter the information requested below.)
NAME OF CHILD WHO
PERSON WITH WHOM CHILD LIVED
LIST EACH MONTH IN WHICH
DID NOT LIVE WITH THE
WORKER IN EACH OF
THIS CHILD DID NOT
RELATIONSHIP TO
THE LAST
NAME AND ADDRESS
LIVE WITH THE WORKER
CHILD
13 MONTHS
17.
If any of the children in item 3 are within 2 months of age 65 or older,
blind or disabled, do you want to file on his/her behalf for Supplemental
Yes
No
Security Income?
PART II - INFORMATION ABOUT THE DECEASED
. Complete items 18 through 26 only if the Worker is deceased.
MONTH, DAY, YEAR
18.
(a) Print date of birth of Worker
(b) Print Worker's name at birth if different from item 1 (a)
(c) Check (X) one for the Worker
Male
Female
19.
(a) Print date of death
MONTH, DAY, YEAR
CITY AND STATE
(b) Print place of death
STATE OR FOREIGN COUNTRY
20.
Print the name of the state or foreign country where the Worker had a
fixed, permanent home at the time of death.
21.
Did the Worker work in the railroad industry for 5 years or more?
Yes
No
22.
(a) Was the Worker in the active military or naval service (including
Yes
No
Reserve or National Guard active duty or active duty for training)
(If "Yes," answer
(If "No," go
after September 7, 1939 and before 1968?
(b) and (c).)
on to item 23.)
FROM (month-year)
TO (month-year)
(b) Enter dates of service
(c) Has anyone (including the Worker) received, or does anyone
Yes
No
expect to receive, a benefit from any other Federal agency?
23.
Yes
No
(a) Did the worker have social security credits (for example, based on
(If "Yes,"
(If "No," go
work or residence) under another country's social security system?
answer (b).)
on to item 24.)
(b) List the country(ies).
24.
Yes
No
(a) Did the worker have wages or self-employment income covered
(If "Yes", skip to
(If "No," answer
under Social Security in all years from 1978 through last year?
item 25.)
(b).)
(b) List the years from 1978 through last year in which the worker did
not have wages or self-employment income covered under
Social Security.
Answer item 25 ONLY if death occurred within the last 2 years.
AMOUNT
25.
(a) About how much did the Worker earn from employment and
self-employment during the year of death?
$
AMOUNT
(b) About how much did the Worker earn the year before death?
$
Form SSA-4-BK (01-2017) UF
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26.
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.
27.
(a) Did the Worker ever file an application for Social Security benefits, a
Yes
No
Unknown
period of disability under Social Security, Supplemental Security
(If "Yes," answer (b) and (c).)
Income, or hospital or medical insurance under Medicare?
(If "No" or "Unknown," go on to item 28.)
(b) Enter name of person(s) on whose Social Security record other
application was filed.
(c) Enter Social Security number of person named in (b).
(If "Unknown," so indicate.)
Answer item 28 ONLY if the Worker died prior to age 66 and within the past 4 months.
(a) Was the Worker unable to work because of a disabling condition at
Yes
No
28.
the time of death?
(If "Yes," answer (b).)
MONTH, DAY, YEAR
(b) Enter date disability began
29.
Were all the children in item 3 living with the Worker at the time of death?
Yes
No
(If "No," enter the following information)
PERSON WITH WHOM CHILD WAS LIVING
NAME OF CHILD NOT LIVING
RELATIONSHIP TO
WITH THE WORKER
NAME AND ADDRESS
CHILD
REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.)
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