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

For additional information about this application a factsheet to Form SSA-7 is
available at www.social security.gov
TEL
Social Security Administration

Form Approved
OMB No 0960-0012

TOE 120/145/155

(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.)

1. (a)
(b)
(c)

2. (a)
(b)

(c)

3. (a)
(b)

PART I

FIRST NAME, MIDDLE INITIAL, LAST NAME
PRINT name of deceased wage earner or
self-employed person (herein referred to as the
"Deceased.")

Check (X) one for the Deceased.

Male

/

Enter Deceased's Social Security number.

FIRST NAME, MIDDLE INITIAL, LAST NAME

/

Enter your Social Security number.

Were you receiving at least one-half of your support from the
Deceased at the time the Deceased became disabled under the
Social Security law or at the time of death?
Have you filed proof of this support with the Social Security
Administration?

No
Yes
(If "Yes," answer (If "No," go on
to item 4.)
(b).)

Yes

MONTH, DAY, YEAR

(c)

No

-- INFORMATION ABOUT THE DECEASED

5. (a)

(b)

/

Enter your name at birth if different from item
2(a).

MONTH, DAY, YEAR

6. (a)

/

PRINT your name.

4. Enter date of birth of Deceased.

(b)

Female

Enter date of death.

CITY AND STATE

Enter place of death.
Did the Deceased ever file an application for Social Security
benefits, a period of disability under Social Security,
Supplemental Security Income, or hospital or medical insurance
under Medicare?
Enter name of person on whose Social Security
record other application was filed.

Yes

No

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

Unknown

(If "No" or "Unknown" go
on to item 7.)

FIRST NAME, MIDDLE INITIAL, LAST NAME

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. (a) Was the Deceased unable to work because of a disabling condition
Yes
No
(If "Yes,"
(If "No," go on
at the time of death?
answer (b).)

(b)

Enter date disability began.

Form SSA-7-F6 (03-2006) EF (03-2006) Destroy all prior editions

to item 8.)

MONTH, DAY, YEAR

Page 1

(Over)

8. (a)

(b)

(c)

Was the Deceased in the active military or naval service (including
Reserve or National Guard active duty or active duty for training) after
September 7, 1939 and before 1968?

Yes
(If "Yes," answer
(b) and (c).)
From: (Month, year)

No
(If "No," go on
to item 9.)
To: (Month, year)

Enter dates of service.
Have you received, or do you expect to receive, a benefit from any
other Federal agency?

Yes

No

Answer Item 9 ONLY If Death Occurred Within the Last 2 Years.
9. (a)
(b)

10. (a)

(b)

About how much did the Deceased earn from employment and
self-employment during the year of death?

AMOUNT
$

Unknown

About how much did the Deceased earn the year before death?

AMOUNT
$

Unknown

Did the deceased have wages or self-employment income covered
under Social Security in all years from 1978 through last year?

Yes
(If "Yes," skip to
item 11.)

No
(If "No," answer
(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 II -- INFORMATION ABOUT YOURSELF
MONTH, DAY, YEAR

12. (a)
Enter your date of birth.
(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)

(d)

13.

Was a public record of your birth made before you were age 5?

Yes

No

Unknown

Was a religious record of your birth made before you were age 5?

Yes

No

Unknown

Yes

No

Yes

No

Have you married since the death of the Deceased?

14. (a)

Have you 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?

Form SSA-7-F6 (03-2006) EF (03-2006)

Page 2

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

(If "No," go on
to item 15.)

(b)
(c)

Enter name of person on whose Social Security record you filed
other application.
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 active duty for training) after September 7,
1939 and before 1968?
16. Did you, your spouse, or the Deceased work in the railroad industry for 5
years or more?
17. (a) Do you have social security credits (for example, based on work or
residence) under another country's social security system?
(b)

/

Yes

No

Yes

No

Yes

(If "Yes,"
answer (b).)

No

(If "No," go on
to item 18.)

List the country(ies).

Answer Item 18 ONLY if the Deceased Died Before This Year.
18. (a)
(b)

19. (a)
(b)

$

How much were your total earnings last year?

ALL

NONE

Place an "X" in each block for EACH MONTH of last year in which you did not earn
more than *$
in wages, and did not perform substantial services in
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

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

$
NONE

ALL

Place an "X" in each block for EACH MONTH of this year in which you did not earn or
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 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 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)
(b)

$

How much do you expect to earn next year?

NONE

ALL

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".

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

21. 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.

MONTH

MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, you will 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, this application may be used for voluntary enrollment.
Form SSA-7-F6 (03-2006) EF (03-2006)

Page 3

(Turn to Page 4)

Complete Item 22 ONLY If You Are Within 3 Months of Age 65 or Older

See addendum
for revised
In most cases, Medicare does not pay for health care you get while traveling outside the United States.
Your local
Social Security office will be glad to explain more about Medicare.
Medicare
Enrollment in Medicare Part B (Medical Insurance): Medicare Part B helps cover doctor's services and
outpatient care.
language

It also covers some other services that Medicare Part A doesn't cover. Once you are enrolled in Medicare Part B, you
will have to pay a monthly permium. The date your Medicare Part B begins and the amount of the premium you must
pay depends on the month you filed this application with the Social Security Administration. Your premiums will be
deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefit check
you receive. If you do not receive such benefits, you will be notified how to pay your premiums. You will get
advance notice if there is any change in your premium amount.
If you do not enroll in Medicare Part B now, you can enroll later only during a specified enrollment period. If you
enroll later, your coverage may be delayed and you may have to pay a higher premium.
22. Do you want to enroll in Medicare Part B (Medical Insurance)?
23. Do you have any unsatisfied felony warrants for
Removed
your arrest?
24.

Questions #23 &
24.
Do you have any unsatisfied Federal or State warrants
for your
arrest for violating the conditions of your probation or parole?

Yes

Yes

No

Yes

No

No

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
USE ONLY

Routing Transit Number

(AREA CODE)
Direct Deposit Payment Address (Financial Institution)
C/S Depositor Account Number
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 (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 (03-2006) EF (03-2006)

Page 4

See below for revised Privacy Act and Paperwork Reduction Act Statements
Collection and Use of Information From Your Application Privacy Act Notice/Paperwork Reduction 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 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 us 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.

Form SSA-7-F6 (03-2006) EF (03-2006)

Page 5

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY PARENT'S INSURANCE BENEFITS
SSA OFFICE
DATE CLAIM RECEIVED
BEFORE YOU RECEIVE A

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

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

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.
Always give us your claim number when writing or telephoning
about your claim.
If you have any questions about your claim, we will be glad to help
you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

DECEASED'S NAME (If surname differs from name of claimant)
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
Change of Marital Status - Marriage, divorce, annulment
residence. (To avoid delay in receipt of checks you
of marriage. You must report marriage even if you
should ALSO file a regular change of address notice with
believe that an exception applies.
your post office.)
Custody Change - Report if a person for whom you are
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 a 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.
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.
Form SSA-7-F6 (03-2006) EF (03-2006)

filing, or who is in your care dies, leaves your care or
custody, or changes address.
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
at the phone number and address 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.
Page 6

Privacy Act Notice/Paperwork Reduction 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 on this form will be used 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.
As permitted under 5 U.S.C. § 552a(b) of the Privacy Act, as amended, SSA may
disclose the information you provide (1) to another Federal, State or local government
agency for determining eligibility for a government benefit or program; (2) to a
Congressional office requesting information on your behalf; (3) to comply with Federal
laws requiring the disclosure of the information from our records; and (4) to facilitate
statistical research, audit or investigative activities necessary to ensure the integrity of
SSA programs.
We 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 us to do
this even if you do not agree to it.
Explanations about these and other reasons why information you provide us 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.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 (TTY 1-800-325-0778).
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.

WORK AND EARNINGS

Privacy Act Notice/Paperwork Reduction 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 on this form will be used 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.
As permitted under 5 U.S.C. § 552a(b) of the Privacy Act, as amended, SSA may
disclose the information you provide (1) to another Federal, State or local government
agency for determining eligibility for a government benefit or program; (2) to a
Congressional office requesting information on your behalf; (3) to comply with Federal
laws requiring the disclosure of the information from our records; and (4) to facilitate
statistical research, audit or investigative activities necessary to ensure the integrity of
SSA programs.
We 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 us to do
this even if you do not agree to it.
Explanations about these and other reasons why information you provide us 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.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 (TTY 1-800-325-0778).
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.