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

TEL

Social Security Administration

Form Approved
OMB No. 0960-0003

TOE 120/145/155

APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*

(Do not write In this space)

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.
The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment. For additional information about this
application a fact sheet to Form SSA-5 is available at www.socialsecurity.gov.
*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) PRINT name of deceased wage earner or
self-employed person (herein referred to as
the "deceased").

FIRST NAME, MIDDLE INITIAL, LAST NAME
X

(b) Check (X) one for the deceased.

X

(c) Enter deceased's Social Security Number.

X

Female

/

/

FIRST NAME, MIDDLE INITIAL, LAST NAME

2.
(a) PRINT your name.

X

(b) Enter your Social Security Number.

3.

Male

X

Enter your name at birth if different
from item 2.

/

/

X

4. (a) Enter your date of birth.

X

MONTH, DAY, YEAR

(b) Enter name of State or foreign country
where you were born.
X
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:
Ɣ under age 16,
Ɣ 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.
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? (This includes adopted child, stepchild, and stepgrandchild.)
(If "Yes," enter the information requested below.)

Yes

X

Name of child

Months child lived with you (If all, write "All")

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.

No

X

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

No
(If "No," go on
to item 7.)

X

(c) Enter Social Security Number of person named in (b).
(If "Unknown," so indicate.)
Form SSA-5-BK (09-2009) EF (09-2009) Destroy Prior Editions

X

Page 1

/

/

7. (a) Are you, or during the past 14 months have you been, unable
X

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

X

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

X

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).

No

Yes

to work because of illnesses, injuries or conditions?

(If "Yes," answer (b).)
Month, Day, Year

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

Yes

No

Yes

No

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

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

X
X

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?
X

Yes
No
(If "Yes," enter the name and address of
the parent(s) in "Remarks".)

11. INFORMATION ON YOUR MARRIAGE(S)
(a) Enter information about your marriage to the deceased.
Spouse's Name (including maiden name)

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:

Spouse's date of birth (or
age)

Date of death

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

(b )If you remarried after the marriage shown in 11. (a), enter information about the last marriage. (If none, write
"NONE").
When (Month, day, year)
Spouse's Name (including maiden name)
Where (Name of City and State)
How marriage ended

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or
age)

If spouse deceased, give date of death

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

Spouse's Social Security Number (If "None" or "Unknown," so indicate)

/

/

(c) If you had other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether
before or after you married the deceased), enter the information below. If you divorced then remarried the same
individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10
years or more, include the marriage. (If none, write "NONE").
Spouse's Name (including maiden name)

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:

Spouse's date of birth (or
age)

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If "None" or "Unknown," so indicate)

/

/

(Use "Remarks" space on next page for continuation)

12. INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)
Answer this item ONLY if the deceased had other marriages.
(a) If the deceased married after his or her marriage to you, enter the information on the last marriage. (If none, write
"NONE").
Spouse's Name (including maiden name)
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:

Spouse's date of birth (or
age)

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If "None" or "Unknown," so indicate)
Form SSA-5-BK (09-2009) EF (09-2009)

Page 2

/

/

12.
(b) Enter information about any other marriage the deceased may have had that lasted at least 10 years (see item 11. (c)
for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or
after you married the deceased). Do not include the marriage to you. (If none, write "NONE").
Spouse's Name (including maiden name)

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:

Spouse's date of birth (or
age)

Date of death

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

Spouse's Social Security Number (If "None" or "Unknown," so indicate)

/

/

(Use "Remarks" space below for marriage continuation. Enter complete information.)

Form SSA-5-BK (09-2009) EF (09-2009)

Page 3

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?

Yes
(If "Yes," go on
to item 14.)

X

No
(If "No," answer
(b).)

(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died, give the
following:
Who was away?

X

Reason absence began

X

Date last at home

X

Reason you were apart at time of death

X

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

X

You

deceased

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

14.

X

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

$

(b) 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."

X

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

15.

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

X

ALL

NONE
JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

$

(b) Place an "X" in each block for EACH MONTH of this year in which you did not 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".
X
*Enter the appropriate monthly limit after reading the instructions, "How Your Earnings
Affect Your Benefits".

NONE

ALL

JAN

FEB

MAR

APR

MAY

JUN

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. (a) How much do you expect to earn next year?

X

$

(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
X
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

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
MONTH
December 31 (with income tax return due April 15), enter here the month
X
your fiscal year ends.
Form SSA-5-BK (09-2009) EF (09-2009)

Page 4

(Turn to Page 5)

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).
X
(b)

I receive a government pension or annuity.
I received a lump sum in place of a government pension or
annuity.
I applied for and am awaiting a decision on my pension or
lump sum.

Yes
No
(If "Yes," check the box in item (b)
that applies.)
(If "No," go on, to item 18.)
I have not applied for but I expect to
begin receiving my pension or annuity:
(If the date is not known, enter
"Unknown.")
Month
Year

18. 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.
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
Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN
HERE

X

FOR
OFFICIAL
USE ONLY

Routing Transit Number

Telephone number(s) at which you
may be contacted during the day

(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 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-BK (09-2009) EF (09-2009)

Page 5

Collection and Use of Information from Your Application
Privacy Act Statement

See Revise Privacy Act Statement
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.
Explanation about reasons why information you provide us may be used or provided to other agencies are
available upon request from a Social Security office.

See Revised Paperwork
Reduction Act
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.

Form SSA-5-BK (09-2009) EF (09-2009)

Page 6

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

SSA OFFICE

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

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
X 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.)

X You go outside the U.S.A. for 30 consecutive days or

longer.
X Any beneficiary dies or becomes unable to handle

X Work Changes -- On your application you told us you

.

(year)

You
than $

(are)

(from the Federal government or any State or any political
subdivision thereof) or your pension or annuity amount
changes.
WORK AND EARNINGS

benefits.

to be $

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.
X You begin to receive a government pension or annuity

X Your citizenship or immigration status changes.

expect total earnings for

X Custody Change or Disability Improves - Report if a

(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.)
X 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.
X 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).

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.
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:
X
X

X You have an unsatisfied warrant for a violation of

X

probation or parole under Federal or State law.
X Change of Marital Status - Marriage, divorce, annulment

of marriage. You must report marriage even if you believe
that an exception applies.
Form SSA-5-BK (09-2009) EF (09-2009)

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.
Page 7

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Notice
Application for Mother’s or Father’s Insurance Benefits

Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine eligibility of you or a
dependent for Social Security benefits.
Furnishing us this information is voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision on your entitlement
or a dependent’s entitlement to Social Security benefit payments.
We rarely use the information you supply for any purpose other than for making a determination
relating to your entitlement or a dependent’s entitlement to Social Security benefit payments.
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 in 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 from Social
Security records (e.g., to the Government Accountability Office and 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 and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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 programs 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 System of Records Notice
entitled, Master Beneficiary Record, 60-0090. This notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your 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 (OMB) control number. The OMB control number for this
collection is 0960-0555. We estimate that it will take 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.