Form SSA-721 Statement of Death by Funeral Director

Form Approved
OMB No. 0960-0142

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF DEATH BY FUNERAL DIRECTOR
SOCIAL SECURITY NUMBER

NAME OF DECEASED

FOR SSA USE ONLY

Please complete the items below, and return the
form in the enclosed addressed, postage paid
envelope. Your assistance and cooperation are
appreciated.

See Revised Privacy Act and PRA Statement Attached
PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the Federal
Regulations (20 CFR 404.715 and 404.720). While your response is voluntary, we need your assistance to make an accurate and timely
determination concerning the death of the individual named above, and to determine if there are survivors who may be eligible for Social
Security benefits.
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 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 3.5 minutes to read the instructions, gather the facts, and answer the questions.
SEND 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, 1338
Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.

1. NAME OF DECEASED

2. SOCIAL SECURITY NUMBER

/
3. DATE OF DEATH

4. DATE OF BIRTH (if known)

/

5. Check (x) whether the deceased was
Male

Female

6. NAME OF WIDOW OR WIDOWER (if known)

7. ADDRESS (No. and Street, P.O. Box) OF WIDOW OR WIDOWER (if known)

CITY

STATE

ZIP CODE

TELEPHONE NUMBER
(if Available)
(area code)

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.

NAME AND ADDRESS OF FUNERAL DIRECTOR OR FIRM

SIGNATURE OF FUNERAL DIRECTOR OR AUTHORIZED
REPRESENTATIVE
TELEPHONE NUMBER
(area code)

FOR SOCIAL SECURITY USE ONLY - DO NOT WRITE IN THIS SPACE
DO Processed (Date)
Form SSA-721 (1-2004) EF (1-2004) Destroy Prior Editions

DATE

A MESSAGE FROM SOCIAL SECURITY
Your funeral director is helping the Social Security office by giving you this
information about Social Security benefits. If the deceased was receiving benefits,
you need to contact us to report the death. If you think you may be eligible for
survivors benefits, you should contact us to apply.
HOW SOCIAL SECURITY HELPS FAMILIES
Social Security survivors benefits help ease the financial burden that follows a
worker's death. Almost all children under age 18 will get monthly benefits if a
working parent dies. Other family members may be eligible for benefits, too.
Anyone who has worked and paid Social Security (FICA) taxes has been
earning Social Security benefits for his or her family. The amount of work needed
to pay survivors benefits depends on the worker's age at the time of death. It may
be as little as 1-1/2 years for a young worker. No one needs more than 10 years.
WHO CAN GET SURVIVORS BENEFITS?
Here is a list of family members who usually can get benefits:
• Widows and widowers age 60 or older.
• Widows and widowers at any age if caring for the deceased's child(ren) who
are under age 16 or disabled.
• Divorced wives and husbands age 60 or older, if married to the deceased
10 years or more.
• Widows, widowers, divorced wives, and divorced husbands age 50 or older, if
they are disabled.
• Children up to age 18.
• Children age 18 - 19, if they attend elementary school or high school full time.
• Children over age 18, if they became disabled before age 22.
• The deceased worker's parents age 62 or older, if they were being supported
by the worker.
A SPECIAL ONE-TIME PAYMENT
In addition to the monthly benefits for family members, a one-time payment of
$255 can be paid to a spouse who was living with the worker at the time of death.
If there is none, it can be paid to:
• A spouse who is eligible for benefits.
• A child or children eligible for benefits.
This payment cannot be made if there is no eligible spouse or child.

Form SSA-721 (1-2004) EF (1-2004)

HOW TO APPLY FOR 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.
INFORMATION NEEDED
• Your Social Security number and the deceased worker's Social Security
number.
• A death certificate. (Generally, the funeral director provides a statement that
can be used for this purpose.)
• Proof of the deceased worker's earnings for last year (W-2 forms or selfemployment tax return).
• Your birth certificate.
• A marriage certificate, if you are applying for benefits as a widow, widower,
divorced wife, or divorced husband.
• A divorce decree, if you are applying for benefits as a divorced wife or
husband.
• Children's birth certificates and Social Security numbers, if applying for
children's benefits.
• Your checking or savings account information, if you want direct deposit of
your benefits.
You will need to submit original documents or copies certified by the issuing office.
You can mail or bring them to the office. Social Security will make photocopies and
return your documents.
SUPPLEMENTAL SECURITY INCOME (SSI)
If you are 65 or older, disabled, or blind, ask the Social Security representative
about Supplemental Security Income (SSI) checks for people with limited income
and resources. If you receive SSI, you may also qualify for Medicaid, food stamps,
and other social services.
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.
A REMINDER
If the deceased was receiving Social Security benefits, any checks which arrive
after death will need to be returned to the Social Security office. If Social Security
checks were being directly deposited into a bank account, the bank needs to be
notified of the death, too.
Form SSA-721 (1-2004) EF (1-2004)

SSA will insert the following revised PRA Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Statement of Death By Funeral Director
Sections 202 and 205 (a) of the Social Security Act as amended, and sections 404.715
and 404.720 of the Code of Federal Regulations (20 C.F.R. 404.715 and 404.720)
authorize us to collect the information on this form. While your response is voluntary,
we need your assistance to make an accurate and timely determination concerning the
death of the individual named above, and to determine if there are survivors who may be
eligible for Social Security benefits.
We rarely use the information you provide about the deceased on this form for any
purpose other than for the reasons stated above. However, we may use it for
administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routines
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 right
to Social Security benefits and coverage, and
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g. to the Government Accountability Office and Department
of Veterans Affairs).
3. 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 about the deceased in Computer Matching
programs. Matching programs compare our records with records kept by other Federal,
State, or local government agencies. Information from these matching programs can be
used to establish or verify a person’s eligibility for Federally-funded and 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 Systems of Record
Notices 60-0058, 60-0090 and 60-0103. This notice, additional information about this
form, and any other information regarding our programs are available on-line at
www.socialsecurity.gov or visit your local 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 3.5
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.