Form SSA-5-F6 Application for Mother's or Father's Insurance Benefits

For additional information about this application a factsheet to
o TEL
Social Security
Administration
Form SSA-5
is available
at www.socialsecurity.gov.

Form Approved
OMB No 0960-0003

TOE 120/145/155

(Do not write In this space)

APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*
I apply for aU 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.
The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment.
-This may also be considerad an application for survivors benefits under the Railroad Ratirement Act and for Veterans
Administration payments under title 38 U.S.C .. Veterans BMefits. Chapter 13 (which is. as such. an application for
other types of death benefits under title 381.

FIRST NAME, M(DDLE INITIAL, LAST NAME

1. (al PRINT name of deceased wage earner or
self-employed person (herein referred to as
~
the "Deceased").

lower case "d"

(b) Check (Xl one for the Deceased.

•

(cl Enter Deceased's Social Security Number.

•

o

Male

Female

___ I __

--­

FIRST NAME, MIDDLE INITIAL, LAST NAME

2.
(a) PRINT your name.

~

___ 1_- L ___

•

(b) Enter your Social Security Number.

3.

o

Enter your name at birth if different
from item 2.

•

4. (a) Enter your date of birth.

•

(b) Enter name of State or foreign country
where you were born.

MONTH. DAY. YEAR

•

lower case "d"
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, such child must be your son. daughter, or legally adopted child who is
entitled to child's benefits on the Deceased's earnings record. lower case "d"
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? (Include natural child, adopted child, stepchild, and
stepgrandchild.)
DYes
D No
(If "Yes, " enter the information requested be/ow.)

•

Months child lived with you (If a/l, write "All")

Name of child

Insert "This" and add "s" to word
"include". See Addendum

6.

(a) Have you (or has someone on your behalf) ever filed an
application for Social Security benefits, a period of disability
under Social Security, Supplemental Security Income, or
hospital or medical insurance under Medicare?
(b) Enter name of person on whose

Social Security record you filed

other application.

•

DYes
(If "Yes, " answer
(b) and (c).)

D

No

(If "No, " go on

to item 7.)

•

(c) Enter Social Security Number of person named in (b).
(If "Unknown, " so indicate.)
Form SSA-5-F6 (01-2006) EF (01-2006) Destroy Prior Editions

•
Page 1

___ 1_- L ___

7.

(a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?

•

(b) Enter the date you became unable to work.

•

8.

Did you work in the railroad industry for 5 years or more?

•

9.

(a)
Do you have Social Security credits (for example, based
on work or residence) under another country's Social
Security system?

•

(b) If "Yes," list the country(ies).

D

D

Yes

No

(If "Yes, " answer (b).) (If "No, " go on to item 8.)

Month, Day, Year

Yes

D

No

DYes

D

No

D

If "Yes, " answer (b).)

(If "No," go on to item 10.)

I

10. Is there a surviving parent (or parents) of the Deceased who was
receiving support from the Deceased at the time of death or at the time
•
the Deceased become disabled?

lower case "d"

D

D

Yes

No

(If "Yes, " enter the name and address of

the parent(s) in "Remarks".)

11. Enter below information about each of your marriages. Include information on your marriage to the Deceased and any
other marriages, whether before or after you married the Deceased. If you are applying for father's benefits, enter the
maiden name of the Deceased.
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:
0 Clergyman or public official
0 Other (Explain in "Remarks")

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

See
Addendum for
revised
Q. 11 &
12.

Your
last
marriage

Spouse's Social Security Number

(IF NONE,
WRITE
"NONE.")

-

-I

I­

-­

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:
0 Clergyman or public official
0 Other (Explain in "Remarks")

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

Your
prev!ous
marriage

(If "None" or ·Unknown," so indicate)

Spouse's Social Security Number

(If "None" or "Unknown,"

so indicate)

---I­

-

I-­

(Use "Remarks" space on back of page for information about any other previous marriage)

12. Enter below the information requested about each marriage of the Deceased, including the marriage to you. (Indicate
your marriage to the Deceased by entering your name; it is not necessary to repeat other information about this marriage
you have already given in item 11.) Enter complete information on all other marriages.
Where (Name of City and State)
When (Month, day, year)
To whom married

Last
marriage
of Deceased

How marriage ended

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:
0 Clergyman or public official
0 Other (Explain in Remarks)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Spouse's Social Security Number

"NONE,'"

-

-I­

I­

-­

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:
0 Clergyman or public official
0 Other (Explain in Remarks)

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

Previous
marriage
of the
Deceased
(IF NONE,
WRITE

(If "None" or "Unknown," so indicate)

Spouse's Social Security Number

(If "None" or "Unknown," so indicate)

--1-­

(Use "Remarks n space on back page for information about any other previous marriage)

Form SSA-6-F6 (01-2006) EF (01-2006)

Page 2

--­

If you are applying for surviving divorced spouse's benefits, omit 13 and go on to item 14.

13. (a)

Were you and the Deceased living together at the same address

when the Deceased died?

0

Yes
No
(If "Yes," go on
(If "No, " answer
lower case "d"
to item 14.)
(bJ.J
(b) If either you or the Deceased were away from home (whether or not temporarily) when the Deceased died, give the
following:
lower case "d"

•

0

Who was away?

•

Reason absence began

•

Date last at home

I

Reason you were apart at time of death

•

If separated because of illness, enter nature of illness or disabling

condition

•

lower case "d"

0

You

Deceased

Answer item 14 ONLY if the Deceased died before this year.

14.

15.

•

(a) How much were your total earnings last year?

$
NONE

I

ALL

(b) Place an "X" in each block for EACH MONTH of last year in which you did not earn
in wages, and did not perform substantial services in
more than *$
self-employment. These months are exempt months. If no months were exempt
months, place an "X" in "NONE". If all months were exempt months, place an "X" in
"ALL."

JAN

FEB

MAR

•

APR

MAY

JUN

*Enter the appropriate monthly limit after reading the instructions, "How Your Earnings
Affect Your Benefits".

JUL

AUG

SEPT

OCT

NOV

DEC

(a) How much do you expect your total earnings to be this year?

-

$
NONE

I

ALL

(b) Place an "X" in each block for EACH MONTH of this year in which you did not or will
in wages, and did not or will not perform substantial
not earn more than * $
services in self-employment. These months are exempt months. If no 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".

JAN

FEB

MAR

•

APR

MAY

JUN

*Enter the appropriate monthly limit after reading the instructions, "How Your Earnings
Affect Your Benefits".

JUL

AUG

SEPT

OCT

NOV

DEC

Answer this item 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).

16.

•

(al How much do you expect to earn next year?

$

(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 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".

•

*Enter the appropriate monthly limit after reading the instructions, "How Your
---­
Earnings Affect Your Benefits".

NONE

I
ALL

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

If you use a fiscal year, that is, a taxable year that does not end December MONTH
31 (with income tax return due April 15), enter here the month your fiscal
year ends.

•

Form SSA-5-F6 (01-2006) EF (01-2006)

Page 3

(Turn to Page 41

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 your own employment and earnings for the Federal Government
of the United States, or one of its States or local subdivisions?

•

(Social Security benefits are not government pensions).

(b)

18.

ONO

Yes

(If "Yes, " check the box in item (b)
that applies.)
(If "No, " go on, to item 18.)

0
0

I receive a government pension or annuity.

I have not applied for but I expect to
begin receiving my pension or annuity:

I received a lump sum in place of a government pension or
annuity.

(If the date is not known, enter
"Unknown. ")

0

I applied for and am awaiting a decision on my pension or
lump sum.

Month

Year

o

Check if applicable:
I am not submitting evidence of the deceased's earnings that are not yet on hislher 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.

19. Do you have any unsatisfied felony warrants for
your arrest?

20.
Do you have any unsatisfied Federal or State warrants for your
arrest for violating the conditions of your probation or parole?

o

Yes

o

No

Yes

o

No

Remove Q. 19 & 20. See Addendum.

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 contacted during the day

Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN

HERE

~

FOR
OFFICIAL

(AREACODE)
Direct Deposit Payment Address (Financial Institution)
Routing Transit Number

CIS

Depositor Account Number

D
D

USE ONLY

No Account
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 (XL 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)

Form SSA-5-F6 (01-2006) EF (01-2006)

Page 4

Collection and Use of Information from Your Application - Privacy Act Notice/Paperwork Act Notice
The Social Security Administration is authorized to collect the information on this form under sections 202, 205,
and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You
do not have to give us the requested information. However, if you do not provide the information, we will be
unable to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to
benefit payments.
The information you provide may be disclosed to another Federal, State or local government agency for
determining eligibility for a government benefit or program, to a Congressional office requesting information on
your behalf, to an independent party for the performance of research and statistical activities, or to the
Department of Justice for use in representing the Federal government.
We may also use this information when we match records by computer. Matching programs compare our
records with those of other Federal, State, or local government agencies. Many agencies may use matching
programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us
to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide may be used or given out are available
in Social Security offices. If you want to learn more about this, contact any Social Security office.

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 control number. We estimate that it will take about 15 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call
Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

See revised Privacy Act and Paperwork Reduction Act
Statements below.

Form SSA-5-F6 (01-2006) EF (01-2006)

Page 5

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY MOTHER'S OR FATHER'S INSURANCE BENEFITS

BEFORE YOU RECEIVE A
NOTICE OF AWARD
TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT

SSA OFFICE

DATE CLAIM RECEIVED

(AREA CODE)

AFTER YOU RECEIVE A
NOTICE OF AWARD
(AREA CODE)

Your application for Social Security benefits has been received
and will be processed as quickly as possible.

some other change that may affect your claim, you or
someone for you should report the change. The changes to
be reported are listed below.

You should hear from us within
days after you
have given us all the information we requested. Some claims
may take longer if additional information is needed.

Always give us your claim number when writing or
telephoning about your claim.

In the meantime, if you have a change of address, or if there is
CLAIMANT

If you have any questions about your claim, we will be glad
to help you.

DECEASED'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY NUMBER

CHANGES TO BE REPORTED AND HOW TO REPORT

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES

.. You change your mailing address for checks or residence.
(To avoid delay in receipt of checks you should ALSO file
a regular change of address notice with your post office.)

.. Custody Change or Disability Improves - Report if a
person for whom you are filing. or who is in your care
dies, leaves your care or custody, changes address, or if
disabled, the condition improves .

.. Your citizenship or immigration status changes.

.. You begin to receive a government pension or annuity
(from the Federal government or any State or any
political subdivision thereof) or your pension or annuity
amount changes.

.. You go outside the U.S.A. for 30 consecutive days or
longer.
.. Any beneficiary dies or becomes unable to handle
benefits.

HOW TO REPORT
You can make your reports by telephone, mail, or in

person, whichever you prefer .

If you are awarded benefits, and one or more of the

above change(s) occur. you should report by:

.. Work Changes
On your application you told us you
to be $
expect total earnings for
(year)
You 0 (are)
(are not) earning wages of more
than $
a month.

--­

.. Calling us TOLL FREE at 1-800-772-1213;
.. If you are deaf or hearing impaired. calling us TOLL
FREE at TTY 1-800-325-0778; or
.. Calling, visiting or writing your local Social Security
office shown on your claim receipt.
For general information about Social Security, visit our
web site at www.socialsecurity.gov.

You 0 (are) 0 (are not) self-employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes.)
.. You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you are
confined to a public institution by court order in
connection with a crime.

insert "at the phone number and address shown."

.. You have an unsatisfied warrant for your arrest for a
crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment for a
term exceeding 1 year.) add period after parenthesis
.. You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.
.. Change of Marital Status - Marriage, divorce, annulment
of marriage. You must report marriage even if you
believe that an exception applies.
Form SSA-5-F6 (01-2006) EF (01-2006)

For those under full retirement age, the law requires that
a report of earnings be filed with SSA within 3 months
and 15 days after the end of any taxable year in which
you earn more than the annual exempt amount. You
may contact SSA to file a report. Otherwise. SSA will
use the earnings reported by your employer(s) and your
self-employment tax return (if applicable) as the report of
earnings required by law and adjust benefits under the
earnings test. It is your responsibility to ensure that the
information you give concerning your earnings is correct.
You must furnish additional information as needed when
your benefit adjustment is not correct based on the
earnings on your record.

Page 6

Instructions Pg. 1

Form Approved
OMB No. 0960-0003

REPORTING RESPONSIBILITIES FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE
REPAID, AND IN POSSIBLE MONETARY PENALTIES
You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)

You begin to receive a government pension or
annuity (from the Federal government or any State
or any political subdivision thereof) or your pension
or annuity amount changes.

Your citizenship or immigration status changes.
You go outside the U.S.A. for 30 consecutive days
or longer.

Any beneficiary dies or becomes unable to handle
benefits.

Work Changes - On your application you told us
you expect total earnings for
to be
$
.

You
than $

(are)

(are not) earning wages of more
a month.

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.

(Report AT ONCE if this work pattern changes)

insert "at the phone number and address shown."
Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report marriage
even if you believe that an exception applies.

Custody Change or Disability Improves - Report if a
person for whom your a filing, or who is in your
care dies, leaves your care or custody, changes
address, or, if disabled, the condition improves.

Delete "r" and replace "a" with
"are".
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you
are confined to a public institution by court order in
connection with a crime.

You have an unsatisfied warrant for your arrest for
a crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment
for a term exceeding 1 year.)

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

Insert new heading "WORK AND EARNINGS"
HOW TO REPORT
You can make your reports by telephone, mail, or in
person, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:
Calling us TOLL FREE at 1-800-772-1213;
If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social Security
office shown on your claim receipt.
For general information about Social Security, visit our
web site at www.socialsecurity.gov.
For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount.
You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if
applicable) as the report of earnings required by law
and adjust benefits under the earnings test. It is your
responsibility to ensure that the information you give
concerning your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

Move this paragraph under new heading above "Work and Earnings."
NOTICE ABOUT DOCUMENTS
We recommend that you keep all documents you submitted to us.
We are returning the documents you submitted with this claim.
Form SSA-5-INST (01-2006) EF (01-2006)

Destroy Prior Editions

update date

Instructions Pg. 2
Collection and Use of Information From Your Application
Privacy Act Notice/Paperwork Act Notice

See Below for Reivsed Privacy Act Language
The Social Security Administration is authorized to collect the information on this form under sections 202, 205, and 223 of the Social
Security Act. The information you provide will be used by the Social Security Administration to determine if you or a dependent is
eligible to insurance coverage and/or monthly benefits. You do not have to give us the requested information. However, if you do not
provide the information, we will be unable to make an accurate and timely decision concerning your entitlement or a dependent's
entitlement to benefit payments.
The information you provide may be disclosed to another Federal, State or local government agency for determining eligibility for a
government benefit or program, to a Congressional office requesting information on your behalf, to an independent party for the
performance of research and statistical activities, or to the Department of Justice for use in representing the Federal government.
We may also use this information when we match records by computer. Matching programs compare our records with those of other
Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for
benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.

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 control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed
under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Insert "should be
provided"

Form SSA-5-INST (01-2006) EF (01-2006)

insert "TTY
1-800-325-0778"

The following Privacy Act Statment will be inserted at the next
scheduled printing.
Collection and Use of Information from Your Application
Privacy Act Notice
The Social Security Administration (SSA) is authorized to collect the information on this
form under sections 202, 205, and 223 of the Social Security Act. The information you
provide will be used by SSA to determine if you or a dependent is eligible to insurance
coverage and/or monthly benefits. While completion of this form is voluntary, failure to
provide all or any part of the requested information may effect our ability to make an
accurate and timely decision concerning your entitlement or a dependent’s entitlement to
benefit payments.
The information you furnish on this form may be disclosed by SSA as generally
permitted under 5 U.S.C. § 522a(b) of the Privacy Act, as amended. This includes using
the information: (1) to assist Social Security in establishing the right of an individual to
Social Security benefits; (2) to facilitate statistical research and audit activities necessary
to assure the integrity and improvement of the Social Security programs; and (3) to
comply with Federal laws requiring the release of information from our records .
SSA may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows SSA to do
this even if you do not agree to it.
Explanations about reasons why information you provide us may be used or provided to
other agencies are available upon request from a Social Security office.