Form SSA-1724 Claim for Amounts Due in the Case of a Deceased Benefici

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB NO. 0960-0101

TOE 210

PRINT NAME OF DECEASED BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER OF
DECEASED BENEFICIARY

If above-named beneficiary received benefits on another NAME OF INSURED
person's record, print name of the insured person
The deceased beneficiary may have been due a Social Security payment at the time of death. The Social Security
Act provides that amounts due a deceased beneficiary may be paid to the next of kin or the legal representative of
the estate under priorities established in the law. To help us decide who should receive any payment due, please
COMPLETE this form and RETURN it to us in the enclosed envelope.
PRINT ADDRESS OF CLAIMANT (Include house number, street,

PRINT NAME OF CLAIMANT

apt. number, P.O. Box, rural route, city state and Zip code.)

CLAIM FOR AMOUNTS DUE IN THE CASE OF DECEASED BENEFICIARY
PRIVACY ACT STATEMENT

The Social Security Administration (SSA) is authorized to collect the
information on this form under Sections 204(d) of the Social Security Act, as
amended (42. U.S.C 404(d)) and section 413(b) of the Federal Mine Safety and
Health Act of 1977 (30 U.S.C. 923). While it is voluntary for you to furnish the
information on this form to SSA, failure to provide the information may result in
nonpayment of the unpaid benefits. The information on this form is needed to
determine if any individual meets the specified qualifications to obtain benefits
in the case of a deceased beneficiary as well as the priority order for payment.
Although the information you furnish on this form is almost never used for any
other purpose than stated in the foregoing, there is a possibility that for the
administration of the Social Security program or for the administration of

programs requiring coordination with SSA, information may be disclosed to
another governmental agency as follows: (1) to assist SSA in deciding who
should receive any payments due the deceased beneficiary; (2) to comply with
Federal laws requiring the release of information from Social Security records
(e.g., to the General Accounting Office and the Veterans Administration); and
(3) to facilitate statistical research and audit activities necessary to assure the
integrity and improvement of the Social Security programs (e.g., to the Bureau
of the Census and private concerns under contract of Social Security).

I am claiming amounts due from the Social Security Administration as the
of

(Name of decedent)

who died on the

day of

fixed permanent home was in the state of

(Indicate your relationship to the deceased
(i.e. widow, son, etc. or legal representative)
(Month)

(Year)

, and whose

.

THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVES OF THE DECEASED PERSON NAMED ABOVE:
1 NAME OF SURVIVING WIDOW(ER) (Please print. If none, ADDRESS OF SURVIVING WIDOW(ER) (Please print
state "NONE".)

2

house number, street, apt. number, P.O., box, rural route,
city, state and ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER)
/
/
NAMED ABOVE. (If unknown, indicate "UNKNOWN".)
WAS THE WIDOW(ER) NAMED ABOVE, LIVING IN THE
(If "YES", OMIT items 2,
4, and 5 and SIGN at
SAME HOUSEHOLD WITH THE DECEASED AT THE
YES 3,
NO
bottom of page 2.)
TIME OF DEATH?
WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT
(If "YES", OMIT items 2,
4, and 5 and SIGN at
ON THE SAME EARNINGS RECORD AS THE DECEASED
YES 3,
NO (Go on to item 2.)
bottom of page 2.)
AT THE TIME OF DEATH?
ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND
NUMBER
STEPCHILDREN; INCLUDE GRANDCHILDREN AND STEPGRANDCHILDREN IF THEIR PARENTS ARE
DISABLED OR DECEASED; OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF
THE DECEASED BENEFICIARY. IF NONE OF THE ABOVE, SHOW "NONE" AND GO ON TO ITEM 4.
PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD
ADDRESS OF CHILD (Include house number, street, apt.
NAME OF CHILD
number, P.O., box, rural route, city, state and ZIP code)

RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.) SOCIAL SECURITY NUMBER(S) OF CHILD (If unknown,
indicate "UNKNOWN".)

NAME OF CHILD

/

/

ADDRESS OF CHILD (Include house number, street, apt.

number, P.O., box, rural route, city, state and ZIP code)

RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.) SOCIAL SECURITY NUMBER(S) OF CHILD (If unknown,
indicate "UNKNOWN".)

/

Form SSA-1724 (11-1984) EF (08-2008)

Over

/

3

IF ANY CHILD LISTED IN ITEM 2 NOW HAS A NAME DIFFERENT FROM THAT GIVEN AT BIRTH, PRINT BELOW
THAT CHILD'S NAME, THE NAME GIVEN AT BIRTH, AND A BRIEF EXPLANATION FOR THE DIFFERENCE.
CHILD'S PRESENT NAME
CHILD'S NAME AT BIRTH
EXPLANATION (Marriage, court order, adoption)

4

ENTER NUMBER OF LIVING PARENTS OF THE DECEASED (Include adopting parents and stepparents. If
none, show "None".)

NUMBER

IF THERE ARE NO LIVING PARENTS, GO ON TO ITEM 5.
PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT
ADDRESS OF LIVING PARENT (Include house number,
NAME OF LIVING PARENT
street, apt. number, P.O. box, rural route, city, state, and
ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF PARENT
NAMED. (If unknown, indicate "UNKNOWN".)

/

street, apt. number, P.O. box, rural route, city, state, and
ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF PARENT
NAMED. (If unknown, indicate "UNKNOWN".)

5

/

ADDRESS OF LIVING PARENT (Include house number,

NAME OF LIVING PARENT

/

/

LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Omit this item if relatives are listed in 1, 2, or 4)
ADDRESS OF LEGAL REPRESENTATIVE (Please print
NAME OF LEGAL REPRESENTATIVE (Please print)
house number, street, apt. number, P.O. box, rural route,
city, state, and ZIP code)

Note: If you are applying as legal representative, please submit a certified copy of your letters of appointment.
REMARKS: (If you need more space for explaining any answers to the questions, attach a separate sheet.)
COMPUTER MATCHING STATEMENT: 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.
PAPERWORK REDUCTION ACT: This information collection meets the clearance 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 you about 10 minutes to read the instructions, gather the necessary facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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.

SIGNATURE OF APPLICANT
SIGNATURE (First name, middle initial, last name)
DATE (Month, day, year) TELEPHONE NUMBER
(Include area code)
MAILING ADDRESS (House number and street, apt. number, P.O. box, or rural route)

CITY

STATE

NAME OF COUNTY

ZIP CODE

WITNESSES ARE REQUIRED ONLY IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X) ABOVE. IF SIGNED BY MARK (X),
TWO WITNESSES TO THE SIGNING WHO KNOW THE APPLICANT MUST SIGN BELOW GIVING THEIR FULL ADDRESSES.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (House number and street, city, state, and ZIP code)

ADDRESS (House number and street, city, state, and

Form SSA-1724 (11-1984) EF (08-2008)

ZIP code)