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

Form Approved

TEL

Social Security Administration

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.) For additional
information about this application a factsheet to Form SSA-7 is available at www.socialsecurity.gov

1. (a)

(b)

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

Male

X

Female

(c)
Enter Deceased's Social Security number.

/

X

/

FIRST NAME, MIDDLE INITIAL, LAST NAME

2. (a)
PRINT your name.

X

(b)
Enter your Social Security number.
(c)

3. (a)

(b)

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

/

X

/

X

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?

X

Have you filed proof of this support with the Social Security
Administration?

X

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

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

Yes

No

PART I -- INFORMATION ABOUT THE DECEASED
4. Enter date of birth of Deceased.
5. (a)

X

Enter date of death.

X

Enter place of death.

X

(b)

(c)

MONTH, DAY, YEAR
CITY AND STATE

(b)

6. (a)

MONTH, DAY, YEAR

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.
X

Yes
X

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.)

/

X

/

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)

(b)

Was the Deceased unable to work because of a disabling condition
at the time of death?
X
Enter date disability began.

Form SSA-7-F6 (01-2010) EF (01-2010) Destroy all prior editions

X

Page 1

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

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

MONTH, DAY, YEAR

(Over)

8. (a)
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?
X

No

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

(b)

(c)

Yes

Enter dates of service.

X

Have you received, or do you expect to receive, a benefit from any
other Federal agency?

X

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

Yes

No

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

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

X

AMOUNT
$

Unknown

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

X

AMOUNT
$

Unknown

(b)

10. (a)

(b)

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

Yes
X

No

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

(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.
X

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
12. (a)
(b)

MONTH, DAY, YEAR

Enter your date of birth.

X

Enter name of State or Foreign country where you were born.

X

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)

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

X

Yes

No

Unknown

(d)

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

X

Yes

No

Unknown

Yes

No

13. (a)
(b)

Have you married since the death of the Deceased?
Enter below the information requested about the marriage.

To whom married

When (Month, day, year) Where (Name of City and State)

How marriage ended (If still in effect, write "Not 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)

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 (01-2010) EF (01-2010)

Page 2

/
Yes
X

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

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

(b)
(c)

Enter name of person on whose Social Security record you filed
other application.

X

Enter Social Security number of person named in (b).
(If "Unknown," so indicate.)

X

/

/

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,
X
1939 and before 1968?

16. Did you, your spouse, or the Deceased work in the railroad industry for 5
years or more?

17. (a)

(b)

X

Do you have social security credits (for example, based on work or
residence) under another country's social security system?
X

Yes

No

Yes

No

Yes

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

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

X

List the country(ies).

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

X

How much were your total earnings last year?
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".

(b)

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

ALL

NONE

X

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

19. (a)

$

X

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

$
NONE

X

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

ALL

JAN

FEB

MAR

APR

MAY

JUN

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) 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
to be exempt months, place an "X" in "ALL".

NONE

X

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

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.

ALL

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

MONTH
X

MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older
you could 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, you will need to contact Social
Security to request enrollment.
Form SSA-7-F6 (01-2010) EF (01-2010)

Page 3

(Turn to Page 4)

Complete Item 22 ONLY If You Are Within 3 Months of Age 65 or Older
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other
services that Medicare Part A doesn't cover, such as some of the services provided by physical and occupational
therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The
amount of your premium will be determined when your coverage begins. In some cases, your premium may be higher
based on information about your income we receive from the Internal Revenue Service. Your premiums will be
deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you
receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You
will also get a letter if there is any change in the amount of your premium.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug
plans and when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY
1-877-486-2048). A Medicare Representative can also tell you about agencies in your area that can help you choose
your prescription drug coverage.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you
with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and
prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY
1-800-325-0778) or visit the nearest Social Security office.
X

22. Do you want to enroll in Medicare Part B (Medical Insurance)?

Yes

No

Select "No" if you are already enrolled under your own Social Security Number.
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

X

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 (01-2010) EF (01-2010)

Page 4

Collection and Use of Information From Your Application Privacy Act Notice/Paperwork Reduction Act Notice

See Revised

The Social Security Privacy
Administration
Act (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 on this form will be used to determine if
Statement
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.

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-7-F6 (01-2010) EF (01-2010)

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.

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

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
X You change your mailing address for checks or residence.
X Change of Marital Status - Marriage, divorce, annulment
(To avoid delay in receipt of checks you should ALSO file
of marriage. You must report marriage even if you
a regular change of address notice with your post office.)
believe that an exception applies.
X
X

Your citizenship or immigration status changes.

X

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

X

Any beneficiary dies or becomes unable to handle
benefits.

X

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.)
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.)

X

WORK AND EARNINGS
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

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
X 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.
X

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

Form SSA-7-F6 (01-2010) EF (01-2010)

Custody Change - Report if a person for whom you are
filing, or who is in your care dies, leaves your care or
custody, or changes address.

Page 6

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Sections 202(h), 205(a), and 223(d) of the Social Security Act authorize us to collect the
information on this form. We will use the information you provide on this form to determine if
you or a dependent is eligible to insurance coverage and/or monthly benefits. Your response to
this request is voluntary. However, failure to provide all or part of the information could prevent
us from making an accurate and timely decision concerning your entitlement or a dependent’s
entitlement to benefit payments.
We rarely use the information you supply for any purpose other than for determining your living
arrangements. 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 Special
Veterans Benefits; (2) to comply with Federal laws requiring the release of information from
Social Security records (e.g., to 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 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.
Additional information regarding this form, routine uses of information, and our programs and
systems, is 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 (OMB) control number. The OMB control number for this
collection is 0960-0012. 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.