Application for Child's Insurance Benefits / Death Claim / SSA-4-BK

See Revised Privacy
Act Statement

See revised Paperwork
Reduction Statement

Application for Child’s Insurance Benefits, form SSA-4-BK
Privacy Act Statement
Collection and Use of Personal Information

Sections 202, 205, and 223 of the Social Security Act as amended, [42 U.S.C. 402, 405,
and 423] authorizes us to collect this information. We will use the information you
provide to help us determine if you or a dependent are eligible for insurance coverage
and/or monthly benefits. The information you provide on this form is voluntary.
However, failure to provide the requested information may prevent us from making an
accurate and timely decision concerning you or a dependent’s entitlement to benefit
payments.
We rarely use the information you provide on this form for any purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency on accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information for Social
Security records (e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State or
local government agencies. Information from these matching agencies can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Claims Folder System, 60-0089 and Medicare Database (MDB) File, 600321. The notices, additional information regarding this form, and information regarding
our system and programs, are available on-line at www.socialsecurity.gov or at any local
Social Security office.

SSA will insert the following revised PRA Statement 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 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.