Form SSA-7-F6 "Application for Parent's Insurance Benefits"

What Is Form SSA-7-F6?

Form SSA-7-F6, Application for Parent's Insurance Benefits, is a document submitted to the Social Security Administration (SSA) by dependent parents of deceased workers with enough Social Security credits to confirm eligibility for SSA benefits. If you are at least 62 years of age and you depended on the deceased wage-earner's financial support at the time of their death, you may claim benefits to ensure the financial future of your family.

Alternate Name:

  • Parent Insurance Benefits Application.

This form was released on December 1, 2018, with all previous editions obsolete. You can download a fillable SSA7-F6 Form through the link below.

ADVERTISEMENT

Form SSA-7-F6 Instructions

Add the following information to your Parent Insurance Benefits Application:

  1. State the name, gender, and social security number of the deceased worker.
  2. Write down your name, social security number, and name at birth if it is different from your current name.
  3. Indicate whether you were receiving more at least half of your financial support from the deceased and whether you have ever filed evidence of this support to the SSA.
  4. Record the deceased's dates of birth and death and place of death. State whether they ever filed for Social Security benefits, Medicare insurance, or Supplemental Security Income.
  5. If the deceased was unable to work because of a disability at the time of death, answer "yes" and indicate the date this disability began.
  6. If the deceased was on active military or naval duty between 1939 and 1968, check the appropriate box and enter the dates of service.
  7. If the death occurred within the last two years, enter the amount of money the worker earned during the year of death and the previous year. Specify the years from 1978 in which the deceased did not have Social Security covered income.
  8. State your date and place of birth. Record the type of your birth records. If you have married since the death of the worker, describe your marriage, and add the spouse's social security number.
  9. Indicate whether you have ever filed for any Social Security benefits.
  10. If you were in the active military or naval service between 1939 and 1968 and you, your current spouse, or the deceased worker worked in the railroad industry for five years or more, answer "yes".
  11. If you have Social Security credits in another country, name this country.
  12. Record your earnings last year and expected income this year and next year.
  13. If you are within three months of 65 years old or older, you can enroll in Medicare Part B by checking the appropriate box.
  14. Sign and date the form. Provide your contact details and the address for the direct deposit payment.

SSA-5-BK Related Forms

ADVERTISEMENT

Download Form SSA-7-F6 "Application for Parent's Insurance Benefits"

312 times
Rate (4.3 / 5) 22 votes
Form SSA-7-F6 (12-2018) UF
Discontinue Prior Editions
Page 1 of 6
Social Security Administration
OMB No. 0960-0012
(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
www.socialsecurity.gov
1. (a) PRINT name of deceased wage earner
FIRST NAME, MIDDLE INITIAL, LAST NAME
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)
FIRST NAME, MIDDLE INITIAL, LAST NAME
PRINT your name.
(b) Enter your Social Security number.
(c) Enter your name at birth if different from
item 2(a).
3.
(a) Were you receiving at least one-half of your
Yes
No
support from the Deceased at the time the
(If "Yes,"
(If "No," go
Deceased became disabled under the
answer (b).)
on to item 4.)
Social Security law or at the time of death?
(b) Have you filed proof of this support with the
Yes
No
Social Security Administration?
PART 1 - INFORMATION ABOUT THE DECEASED
4.
Enter date of birth of Deceased.
MONTH, DAY, YEAR
5.
(a) Enter date of death.
MONTH, DAY, YEAR
(b) Enter place of death.
CITY AND STATE
6.
(a) Did the Deceased ever file an application
Yes
No
Unknown
for Social Security benefits, a period of
disability under Social Security,
(If "Yes,"
(If "No" or "Unknown" go on
Supplemental Security Income, or hospital
answer (b)
to item 7.)
or medical insurance under Medicare?
and (c).)
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name of person 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 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.
7.
Yes
No
(a) Was the Deceased unable to work because
of a disabling condition at the time of death?
(If "Yes,"
(If "No," go on
answer (b).)
to item 8.)
(b) Enter date disability began.
MONTH, DAY, YEAR
Form SSA-7-F6 (12-2018) UF
Discontinue Prior Editions
Page 1 of 6
Social Security Administration
OMB No. 0960-0012
(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
www.socialsecurity.gov
1. (a) PRINT name of deceased wage earner
FIRST NAME, MIDDLE INITIAL, LAST NAME
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)
FIRST NAME, MIDDLE INITIAL, LAST NAME
PRINT your name.
(b) Enter your Social Security number.
(c) Enter your name at birth if different from
item 2(a).
3.
(a) Were you receiving at least one-half of your
Yes
No
support from the Deceased at the time the
(If "Yes,"
(If "No," go
Deceased became disabled under the
answer (b).)
on to item 4.)
Social Security law or at the time of death?
(b) Have you filed proof of this support with the
Yes
No
Social Security Administration?
PART 1 - INFORMATION ABOUT THE DECEASED
4.
Enter date of birth of Deceased.
MONTH, DAY, YEAR
5.
(a) Enter date of death.
MONTH, DAY, YEAR
(b) Enter place of death.
CITY AND STATE
6.
(a) Did the Deceased ever file an application
Yes
No
Unknown
for Social Security benefits, a period of
disability under Social Security,
(If "Yes,"
(If "No" or "Unknown" go on
Supplemental Security Income, or hospital
answer (b)
to item 7.)
or medical insurance under Medicare?
and (c).)
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name of person 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 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.
7.
Yes
No
(a) Was the Deceased unable to work because
of a disabling condition at the time of death?
(If "Yes,"
(If "No," go on
answer (b).)
to item 8.)
(b) Enter date disability began.
MONTH, DAY, YEAR
Form SSA-7-F6 (12-2018) UF
Page 2 of 6
8. (a) Was the Deceased in the active military or naval
Yes
No
service (including Reserve or National Guard active
(If "Yes,"
(If "No," go on to
duty or active duty for training) after September 7,
answer (b) and (c).)
item 9.)
1939 and before 1968?
From: (Month, year)
To: (Month, year)
(b) Enter dates of service.
(c) Have you received, or do you expect to receive, a
Yes
No
benefit from any other Federal agency?
Answer Item 9 ONLY If Death Occurred Within the Last 2 Years.
9.
(a) About how much did the Deceased earn from
employment and self-employment during the year
AMOUNT $
Unknown
of death?
(b) About how much did the Deceased earn the
AMOUNT $
Unknown
year before death?
10.
(a) Did the deceased have wages or self-employment
Yes
No
income covered under Social Security in all years
from 1978 through last year?
(If "Yes," skip to
(If "No," answer
item 11.)
(b).)
(b) List the years from 1978 through last year in which
the deceased did not have wages or self-
employment income covered under Social Security.
11. 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.
PART 2 - INFORMATION ABOUT YOURSELF
12.
(a) Enter date of birth.
MONTH, DAY, YEAR
(b) Enter name of State or Foreign country where you
were born.
If you have already presented, or if you are now presenting, a public or religious record of your birth established
before you were age 5, go on to item 13.
(c) Was a public record of your birth made
Yes
No
Unknown
before you were age 5?
(d) Was a religious record of your birth made
Yes
No
Unknown
before you were age 5?
(a) Have you married since the death of
13.
Yes
No
the Deceased?
(b) Enter below the information requested about the marriage.
To whom married
When (Month, day, year) Where (Name of City and State)
How marriage ended (If still in effect, write "Not 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)
14.
(a) Have you ever filed an application for Social
Yes
No
Security benefits, a period of disability under Social
(If "Yes," answer
(If "No," go on to
Security, Supplemental Security Income, or
(b) and (c).)
item 15.)
hospital or medical insurance under Medicare?
Form SSA-7-F6 (12-2018) UF
Page 3 of 6
(b) Enter name of person on whose Social Security
record you filed other application.
(c) Enter Social Security number of person named in
(b). (If "Unknown," so indicate.)
15. Were you in the active military or naval service
(including Reserve or National Guard active duty or
Yes
No
active duty for training) after September 7, 1939 and
before 1968?
16.
Did you, your spouse, or the Deceased work in the
Yes
No
railroad industry for 5 years or more?
17. (a) Do you have social security credits (for example,
Yes
No
based on work or residence) under another
country's social security system?
(If "Yes,"
(If "No," go on
answer (b).)
to item 18.)
(b) List the country(ies).
Answer Item 18 ONLY if the Deceased Died Before This Year.
18.
(a) How much were your total earnings last year?
$
(b) Place an "X" in each block for EACH MONTH of last year in which you did not earn
NONE
ALL
more than *$
in wages, and did not perform substantial services in self-
employment. These months are exempt months. If no months were exempt months,
Jan.
Feb.
Mar.
Apr.
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 Earnings
Sept.
Oct.
Nov.
Dec.
Affect Your Benefits".
19.
(a) How much do you expect your total earnings to be this year?
$
(b) Place an "X" in each block for EACH MONTH of last year in which you did not earn 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 months are or
Jan.
Feb.
Mar.
Apr.
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 Earnings
Sept.
Oct.
Nov.
Dec.
Affect Your Benefits".
Answer This Item ONLY if You Are Not in the Last 4 Months of Your Taxable Year (Sept., Oct., Nov., and Dec., if Your
Taxable Year is a Calendar Year).
20.
(a) How much do you expect to earn next year?
$
Place an "X" in each block for EACH MONTH of next year in which you do not expect to
NONE
ALL
earn more than *$
in wages, and do not expect to perform substantial
services in self-employment. These months will be exempt months. If no months are
Jan.
Feb.
Mar.
Apr.
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 Earnings
Sept.
Oct.
Nov.
Dec.
Affect Your Benefits".
21.
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.
MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you could
automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you
are not eligible for automatic enrollment in Medicare Part B, you will need to contact Social Security to request enrollment.
(Turn to Page 4)
Form SSA-7-F6 (12-2018) UF
Page 4 of 6
Complete Item 22 ONLY If You Are Within 3 Months of Age 65 or Older
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that
Medicare Part A doesn't cover, such as some of the services provided by physical and occupational therapists and some home
health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be
determined when your coverage begins. In some cases, your premium may be higher based on information about your income
we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad
Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a
letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.
Late Enrollment Penalty
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have
Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but did not
sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to March 31) to enroll in Part B, and
coverage will start July 1 of that year.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and
when you can enroll visit
www.medicare.gov
or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). A Medicare
Representative can also tell you about agencies in your area that can help you choose your prescription drug coverage.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription co-
payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the
nearest Social Security office.
22.
Do you want to enroll in Medicare Part B (Medical
Insurance)?
Yes
No
Select "No" if you are already enrolled under your own
Social Security Number.
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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 or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
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
HERE
(AREA CODE)
Direct Deposit Payment Address (Financial Institution)
FOR
OFFICIAL
Routing Transit Number
C/S Depositor Account Number
No Account
USE ONLY
Direct Deposit Refused
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks," 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 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)
Form SSA-7-F6 (12-2018) UF
Page 5 of 6
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 205, 223, 226, and 806 of the Social Security Act, as amended, allow us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and
timely decision on your entitlement to Social Security benefit payments.
We will use the information to determine your eligibility for Social Security benefits. We may also share your information for the
following purposes, called routine uses:
• To Federal, State, or local agencies (or agents on their behalf) for administering income maintenance or health maintenance
programs (including programs under the Social Security Act). Such disclosures include, but are not limited to, release of
information to: Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance Act and for administering provisions
of the Social Security Act relating to railroad employment; and Department of Veterans Affairs for administering 38 U.S.C.
1312, and upon request, for determining eligibility for, or amount of, veterans benefits or verifying other information with
respect thereto pursuant to 38 U.S.C. 5106; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration
(SSA) in the efficient administration of its programs. We will disclose information under the routine use only in situations in
which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function
relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059, Earnings Recording
and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819; 60-0089,
entitled Claims Folders Systems, as published in the FR on April 1, 2003, at 68 FR 15784; 60-0090, entitled Master
Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and 60-0321, entitled Medicare Database, as
published in the FR on July 25, 2006, at 71 FR 42159. Additional information and a full listing of all our SORNs are available on
our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
- This information collection meets the requirements of 44 U.S.C. § 3507, as 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. The OMB control number for this collection is 0960-0012. We estimate that it
will take 15 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.
Page of 6