Addendum to 0960-0142

ADDENDUM TO THE SUPPORTING STATEMENT

FOR FORM SSA-721, STATEMENT OF DEATH BY FUNERAL DIRECTOR

OMB No. 0960-0142

SSA is adding the following language to Form SSA-721 for clarification purposes:

• Perjury Statement: I hereby certify that I am an authorized funeral director and prepared for final disposition of the person named above. I declare under 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.

• How to Apply For Benefits: How you sign up for Social Security benefits depends on whether or not you are getting other Social Security benefits. If you aren’t getting Social Security benefits, you can apply for benefits by telephone or by going to any Social Security office. You may need some of the documents shown on the list below. But don’t delay your application because you don’t have all the information. If you don’t have a document you need, Social Security can help you get it.

• How to Apply For Benefits (continued): If you’re already getting benefits as a wife or husband on your spouse’s record when he or she dies, in many situations we can change your payments to survivors benefits once you report the death to us. Benefits for any children will also automatically be changed to survivors benefits after the death is reported to us.

• For More Information: For more information, write or visit any Social Security office, or phone the toll-free number, 1-800-772-1213. You can speak to a representative weekdays 7 a.m. to 7 p.m. You can also visit Social Security’s internet website: www.socialsecurity.gov.

All of the new language is on a new page 3 of the form. Since this information is not required, we will implement it after we have used up our existing stock of forms.

0960-0142 (SSA-721)

Addendum to the Supporting Statement