Form SSA-8-F4 Application For Lump-Sum Death Payment

TOE 120/145/155

Social Security Administration

Form Approved
OMB No. 0960-0013

APPLICATION FOR LUMP-SUM DEATH PAYMENT*
I apply for all insurance benefits for which I am eligible under Title II (Federal OldAge, Survivors, and Disability Insurance) of the Social Security Act, as presently
amended, on the named deceased's Social Security record.
(This application must be filed within 2 years after the date of
death of the wage earner or self-employed person.)
* This may also be considered an application for insurance benefits payable
under the Railroad Retirement Act.

1. (a) PRINT name of Deceased Wage Earner

FIRST NAME, MIDDLE INITIAL, LAST NAME

or Self-Employed Person
(herein referred to as the "deceased")

Male

(b) Check (X) one for the deceased

/

(c) Enter deceased's Social Security Number

2.

Female

/

FIRST NAME, MIDDLE INITIAL, LAST NAME
PRINT your name

3. Enter date of birth of deceased
(Month, day, year)

4. (a) Enter date of death
(Month, day, year)

(b) Enter place of death
(City and State)

5. (a) Did the deceased ever file an application for Social Security

Yes
No
Unknown
benefits, a period of disability under Social Security,
(If "No" or "Unknown,"
(If "Yes," answer
supplemental security income, or hospital or medical
go on to item 6.)
(b) and (c).)
insurance under Medicare?
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name(s) of person(s) on whose
Social Security record(s) other
application was filed.
(c) Enter Social Security Number(s) of person(s) named in (b).
(If unknown, so indicate)

/

/

6. ANSWER ITEM 6 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.
(a) About how much did the deceased earn from employment
and self-employment during the year of death?
(b) About how much did the deceased earn the year before
death?

7.

AMOUNT
$
AMOUNT
$

ANSWER ITEM 7 ONLY IF THE DECEASED DIED PRIOR TO AGE 66 AND WITHIN THE PAST 4 MONTHS.
(a) Was the deceased unable to work because of illness, injuries
or conditions at the time of death?

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

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

(b) Enter the date the deceased became unable to work
(Month, day, year)

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?

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

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

(b) Enter dates of service.
(c) Has anyone (including the deceased) received, or does
anyone expect to receive, a benefit from any other
Federal agency?

9. Did the deceased work in the railroad
industry for 7 years or more?

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Yes

No

Yes

No

10. (a) Did the deceased ever engage in work that was covered

under the social security system of a country other than the
United States?

Yes
No
(If "Yes," answer (b).) (If "No," go on to item 11.)

(b) If "Yes," list the country(ies).

11. (a) Is the deceased survived by a spouse?

If "Yes", enter information about the marriage in effect at the time of death below. If
"No", go on to item 11(b) if the deceased had prior marraiges or item 12 if the
deceased never married.

No

Yes

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)

Spouse's date of birth (or age)

Spouse's Social Security Number (If none or
unknown, so indicate)

Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")

/

/

(b) If the deceased had a prior marriage(s) that lasted at least 10 years, enter the information below. If the deceased
married the same individual multiple times and the remarriage took place 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 or unknown, so indicate.
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)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)

/

Spouse's Social Security Number (If none or unknown, so indicate)

/

(c) If the deceased has surviving children as defined in item 12 and he or she was married to the child's mother or
father but the marriage ended in divorce, enter information on the marriage if not already listed in 11(b)..
If none or unknown, so indicate.
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)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

/

/

12. The deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent
grandchildren (including stepgrandchildren) may be eligible for benefits based on the earnings record of the
deceased.
List below ALL such children who are now or were in the past 12 months UNMARRIED and:
• UNDER AGE 18 • AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

(If none, write ''None.'')
Full Name of Child

Full Name of Child

13. Is there a surviving parent (or parents) of the deceased who was

receiving support from the deceased either at the time the
deceased became disabled under the Social Security law or at the
time of death?

14. Have you filed for any Social Security benefits on the deceased's
earnings record before?

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

NOTE: If there is a surviving spouse, continue with item 15. If not, skip items 15 through 18.

15. If you are not the surviving spouse, enter the surviving spouse's name and address here

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No

Yes

16. (a) Were the deceased and the surviving spouse living together
at the same address when the deceased died?

No

(If "Yes," go on to item 17.) (If "No," answer (b).)

(b) If either the deceased or surviving spouse was away from home (whether or not temporarily) when the deceased
died, give the following:
Who was away?
Deceased
Surviving spouse
Date last home

Reason absence began

Reason they were apart at time of death

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

If you are the surviving spouse, and If you are under age 66, answer 17.
you so disabled that you cannot work or was there some
17. (a) Are
period during the last 14 months when you were so disabled
that you could not work?

No

(Month, day, year)

(b) If ''Yes,'' enter the date you became disabled.

18.

Yes

Answer 18 ONLY if you are the surviving spouse.
Were you married before your marriage to the deceased?

Yes

If yes, enter information about your prior marriage(s) that lasted at
least 10 years or ended due to death of the spouse. 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 at least 10 years, include the marriage.
If you need more space, use "Remarks" section on back page or
attach a separate sheet.

No

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)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)

Spouse's Social Security Number (If none or unknown, so indicate)

/

/

For additional information about survivor benefits see our publication at www.socialsecurity.gov.
Remarks: (You may use this space for any explanation. 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.
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number(s) at Which You May Be
Contacted During the Day

u

(Area Code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Enter Name of 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.
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)

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RECEIPT FOR YOUR CLAIM FOR THE SOCIAL SECURITY LUMP-SUM DEATH PAYMENT
TELEPHONE NUMBER TO CALL IF YOU HAVE A QUESTION
OR SOMETHING TO REPORT

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER

RECEIPT FOR YOUR CLAIM
Your application for the lump-sum death payment has
been received and will be processed as quickly as
possible.
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.

CLAIMANT

In the meantime, if you change your mailing address, you
should report the change.
Always give us your claim number when writing or
telephoning about your claim.
If you have any questions about your claim, we will be glad
to help you.
SOCIAL SECURITY CLAIM NUMBER

DECEASED'S NAME (If surname differs from claimant's name)

Privacy Act Statement - Application for Lump-Sum Death Payment

See
Sections 202(g), 205(a), 223, and 1631 of the Social Security Act, as amended, authorize us to collect this information.
TheRevised
information you provide will allow the Social Security Administration (SSA) to determine your potential eligibility for benefit
payments and to help us to decide if additional information is needed. Your response is voluntary. However, failure to provide this
requested information may prevent an accurate and timely decision on any claim filed, or could result in loss of benefits.
We rarely use the information provided on this form for any purpose other than for the reasons stated 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 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 Medicare benefits 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 determination 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 Medicare programs.
We may also use the information you provide in computer matching programs. Matching programs compare our 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.
Explanations about these and other reasons why information you provide us may be used or given out are available in Systems of
Record Notice 60-0089 (Claims Folders Systems, SSA, Office of General Counsel, Office of Privacy and Disclosure). The Notice
information about this form, and any other information regarding our systems and programs, are available on-line at
www.socialsecurity.gov or visit your local Social Security office.

See Revised PRA

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 10 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 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.
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PAS