Form SSA-4-BK Application for Child's Insurance Benefits

D

Social Security Administration

TEL

Form Approved
OMB No. 0960-0010

TOE 120/145/155

(Do not write in this space)

APPLICATION FOR CHILD'S INSURANCE BENEFITS
With this application, you are applying on beha f of the child or children listed in item 3 below for all insurance
benefits fo r which they may be eligible under T le II (Federal Old-Age, Survivors, and Disability lnsur:ance) of the
Social Secu rity Act as presently amended. If yo are applying on your own behalf, answer the questions on this
form with r espect to yourself.
If you are applying for benefits base< on the earnings record of a Deceased Worker, this may also be
considered an application for surv vors 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 t enefits under Title 38).

1.

LIFE
CLAIM

DEATH
CLAIM

D

D

FIRST NAME, MIDDLE INITIAL, LAST NAME

(a) PRINT name of Wage Earne or Self-Employed person
(herein referred to as the "V1 orker"),

(

(b) PRINT Worker's Social Seci.J rity number.

- - - I - - I- - - FIRST NAME, MIDDLE INITIAL, LAST NAME

2.
(a) PRINT your name (unless yc u are the Worker).
(b) PRINT your Social Security umber.

- - - I - - I- - - -

PART I-INFORMATION ABOUT THE ~ORKER'S CHILDREN

3.
The Worker's children (includin natural children, adopted children, and stepchildren) or dependent grandchildren (including
step grandchildren) may be e igible for benefits based on the earnings record of the Worker. For a living Worker
the information below applies t this month or to any of the past 12 months. For a deceased Worker, the information belo w
applies to the date of death or or any period since the Worker's death.

UNDER AGE 18
AGE 18 TO 19 AND ATTENDING E EMENTARYOR
SECONDARY SCHOOL FULL-TIME
DISABLED OR HANDICAPPED (ag 18 or over and
disability began before age 22)

Check Date of
Check (X) if
(XI Sex
Birth
Child 17 or
(Mo., day,
of
Older is:
Child
yr.)

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~::heck (X) the
Column That
Shows Child's
Relationship to
Worker

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CHILD'S SOCIAL
SECURITY NUMBER

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ie 5

Cl!l

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FULL NAME OF CHILD

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----

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If you do not wish to be payee or any child or dependent grandchild named above, list the child's name and address in
"Remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits.

4.

If any children in item 3 are ste ~children of the Worker, enter the
date the Worker married the na ural parent.

5.
(a) Is there a legal representativ ~ (guardian, conservator, curator,
etc.) for any of the children i item 3?

r

Form SSA-4-BK (12-2010) EF (12-201< ) Destroy Prior Editions

Page 1

MONTH, DAY, YEAR

D

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

0No
(If "No," go on to
item 6.)
(over)

(b) Write the following
information about the
legal representative(s):

NAME (First na me, middle initial, last name)

TELEPHONE NUMBER
(INCLUDE AREA CODE)

ADDRESS

(c) Briefly explain the circumstance which led the court to appoint a legal representative.

6. · Are you the natural or adoptive pare nt of the person(s) for whom you are
filing?

7.

8.

Have any children in item 3 ever be n adopted by someone other than the
Worker? (If "Yes," enter the followi g information):
Name of Child
Date of Adoption

Are all the children in item 3 now li\ ing in the same household with you? (If
"No," enter the following informatio :1 about each child not living with you. If
uncertain a$ to the whereabouts of ny of these children, explain in
"Remarks".)
Name of Child Not Living With You

9.

DYes

DNa

DYes

DNa

Name of Person Adopting

DYes

Person With Whom Child Now Lives
Name and Address

Has any child in item 3 ever been m rried?
(If "Yes, " enter the information reqt.J ested below.)

DYes

DNa

Relationship to Child

DNa

Name of Child

Date of Marriage (Month, day, year)

How Marriage Ended (If still married write "not ended").

Date Marriage Ended (Month, day, year)

10; Has anyone ever before filed an app ication with the Social Security
Administration for monthly benefits pn behalf of any child in item 3? (If
"Yes," enter below the name(s) oft e child(ren) and the name(s) and Social
DYes
DNa
Security number(s) of the person(s) pn whose earnings record any other
claim was based.)
Social Security Number of Worker
N me of Worker
Name of Child

--- I - - I ------ I -- I ------ I - - I ---Form SSA-4-BK (12-201 0) EF (12-201 0)

Page 2

--- I -- I ----

If you are applying ONLY for a child ~ge 18 or over who is disabled, omit items 11 through 14. In all other cases, answer items
11 through 14.
EARNINGS INFORMATION FOR LAS YEAR (Do not complete if the Worker died this year)
11.
(a) Did any child in item 3 earn more than the exempt amount last year?(lf
DYes
"Yes," answer (b). If "No," o on to item 12.)
(b)

NAME OF CHILD WHO EARNED
OVER THE EXEMPT AMOUNT
LAST YEAR

0No

LIST EACH MONTH THAT CHILD DID NOT EARN
MORE THAN$
IN WAGES AND DID NOT
PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

TOTAL EARNINGS
OF CHILD

$
$
$
EARNINGS INFORMATION FOR THIS YE R

12.

(a) Do you expect the total ear ings of any child in item 3 to be more than
the exempt amount this ye; r? (Count all earnings beginning with the first
of this year and all anticipat ed earnings through the end of this year.) (If
"Yes," answer (b). If "No," go on to item 13.)
(b)

NAME OF CHILD WHO EXPECTS
TO EARN OVER THE
EXEMPT AMOUNT THIS YEAR

EXPECTED EARNINGS
OF CHILD

DYes

D

No

LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD
DID NOT OR WILL NOT EARN MORE THAN $
IN WAGES AND DID
NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

$
$
$
Complete item 13 ONLY if any child snow in the last 4 months of the child's taxable year (Sept., Oct., Nov .. and Dec., if the
taxable year is a calendar year).
EARNINGS INFORMATION FOR NEX YEAR
13.
(a) Do you expect the total earr ings of any child in item 3 to be more than
the exempt amount next ye r? (If "Yes," answer (b.) If "No," go on to
No
DYes
D
item 14.)
(b)

NAME OF CHILD WHO EXPECTS
TO EARN OVER THE
EXEMPT AMOUNT NEXT YEAR

LIST EACH MONTH THAT CHILD WILL NOT EARN
MORE THAN$
IN WAGES AND WILL NOT
PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

EXPECTED EARNINGS
OF CHILD

$
$
$
14.

If any of the children for whom you are filing uses a fiscal year (one that does
not end on December 31). print here the name of the child and the month the
fiscal year ends.

NAME OF CHILD AND MONTH FISCAL YEAR ENDS

Com lete items 15 and 16 ONLY if t t"le Worker is livina. Otherwise, go on to item 17.
15. If any children in item 3 are chi l~ren adopted by the Worker, print below the name of each such child and the date of
adoption by the Worker.
NA~

E OF ADOPTED CHILD

Form SSA-4-BK (12-2010) EF (12-201C)

DATE OF ADOPTION

Page 3

(Turn to page 4)

16.

Have all of the children in item 3 liv ~d with the Worker during each of the
last 13 months (counting the prese t month)?
(If "No," enter the information requ ~sted below.)
NAME OF CHILD WHO DID NOT
LIVE WITH THE WORKER IN EACH
OF THE LAST 13 MONTHS

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NAME AND ADDRESS

it~ 3fa

e a~saysfied tel~ wfrant for "\.

the
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her arre

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e an uns~d Federal ~ate warran~
nditions
/her prob~
or
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to violating

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PART II- INFORMATION ABOUT TH

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If any of the children in item 3 are ~ vithin 2 months of age 65 or older, blind
or disabled, do you want to file on is/her behalf for Supplemental Security
Income?

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Yes

0No

MONTH, DAY, YEAR

(a) Print date of birth of Worker
(b) Print Worker's name at birth if d fferent from item 1 (a)

D

Male

D

Female

MONTH, DAY, YEAR

(a) Print date of death

CITY AND STATE

(b) Print place of death

oJ:J)1.

A

DECEASED. Complete items'Wthrough!i! only if the Worker is deceased.

(c) Check (X) one for the Worke

J'f-

RELATIONSHIP TO CHILD

vv•:n a"' VI Lll"' uaL"' .... , • .,

1"'\ D_o ~ of ~il~ren in
!vis/ r arrest?

1

0No

PERSON WITH WHOM CHILD LIVED

Ll T EACH MONTH IN WHICH
THIS CHILD DID NOT
IVE WITH THE WORKER

.....

DYes

Print the name of the state or fo eign country where the Worker had
a fixed, permanent home at the ime of death.
Did the Worker work in the railroad ·ndustry for 5 years or more?
(a) Was the Worker in the active mi itary or naval service (including Reserve
or National Guard active duty or active duty for training) after
September 7, 1 939 and before 968?

STATE OR FOREIGN COUNTRY

DYes

.P

Yes
(If "Yes," answer (b)
and (c).)
FROM (month-year)

(b) Enter dates of service

(c) Has anyone (including the W< rker) received, or does anyone
expect to receive, a benefit f om any other Federal
agency?

DYes

0No
.hJ,No
(If "No," go on
to item ~-l~3
TO (month-year)

0No

~-

J3

(a) Did the worker have social secu ity credits (for example, based on work
or residence) under another cou try's social security system?

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

DNo
(If "No," go on to
item~)~

Yes
D
(If "Yes", skip to
item

0No
(If "No," answer
(b).)

(b) List the country(ies).
;)tfr.

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(a) Did the worker have wages or s lf~employment income covered under
Social Security in all years from 1 978 through last year?

Ji'f-hJt:j

(b) List the years from 1 978 throug last year in which the worker did not
have wages or self-employment income covered under Social
Security.
Form SSA-4-BK

(12~2010)

EF

(12~2010)

Page 4

cVL:'
Answer item

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ONLY if death o ccurred within the last 2 years.

(a) About how much did the Worker earn from employment and
self-employment during the wear of death?

AMOUNT
$

(b) About how much did the W prker earn the year before death?

AMOUNT
$

Check it applicable:
I am not submitting ~vidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these ear pings will be included automatically within 24 months, and any increase in my benefits
will be paid with full retroactivity.

D

(a) Did the Worker ever file an pplication for Social Security benefits, a
period of disability under So ~ial Security, Supplemental Security Income,
or hospital or medical insure rce under Medicare?

DYes

Ounknown

0No

(If "Yes," answer (b) and (c).) (If "No" or
"Unknown," go on to item ~.)

ol~

(b) Enter name of person(s) on tvhose Social Security record other application
was filed.
(c) Enter Social Security numbe of person named in (b).
(If ']~known," so indicate.)
0

Answer item ~ ONLY if the Worker ied prior to age 66 and within the past 4 months.

~

(a) Was the Worker unable to "" ork because of a disabling condition at the
time of death?

9

Were all the children in item 3 lijving with the Worker at the time of death? (If
"No," enter the following inforn ation)
NAME OF CHILD NOT LIVING
WITH THE WORKER

I

--

I

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

D

Yes

D

No

D

No

PERSON WITH WHOM CHILD WAS LIVING
NAME AND ADDRESS

RELATIONSHIP TO CHILD

REMARKS: (You may use this space or any explanations. If you need more space, attach a separate sheet.)

Form SSA-4-BK (12-201 0) EF (12-201 0

----

MONTH, DAY, YEAR

(b) Enter date disability began

/f.

-

Page 5

I

Can't Remarks

I declare under penalty of perjury that I h ve -examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the be ~t of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fac ~ in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penaltie ~.or both.
DATE ( Month, day, year)
SIGNA URE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)
SIGN

HERE

~
.

-

·--

TELEPHONE NUMBERSIS) AT WHICH YOU MAY BE
CONTACTED DURING THE DAY !INCLUDE AREA CODE)

o

A

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·-·

-

....

---

(AREA CODE)

... ..

DIRECT DEPOSIT PAYMI NT INFORMATION (FINANCIAL INSTITUTION)
Routing Transit Number
A ceo ~nt Number
DEnroll in Direct Express
OChecking
OSavings

-

DDirect Deposit Refused

Applicant's Mailing Address (Number and stre1 t, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks, • if different.)

ZIP Code

City and State

County (if any) in which you now live

Witnesses are required ONLY if this appli ation has been signed by mark (X) above. If signed by mark (X). two witnesses to the
signing who know the applicant must sig below giving their full addresses. Also, print the applicant's name in the signature
block.
2. Signature of Witness

1. Signature of Witness
Address (Number and Street, City, State

and~

Form SSA-4-BK (12-2010) EF (12-2010)

IP Code)

Address (Number and Street, City, State and ZIP Code)
Page 6

Priv

See Revised PAS
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this information. We
will use the information you provid to determine if you or a dependent are eligible for insurance coverage and/or
monthly benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested information may
prevent us from making an accurat and timely decision concerning your or a dependent's entitlement to benefit
payments.
We rarely use the information yo supply for any purpose other than for determining the identity of a
spouse. However, we may use it fa the administration and integrity of Social Security programs. We may also
disclose information to another per on or to another agency in accordance with approved routine uses, which
include but are not limited to enabl a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or cov rage, to comply with Federal laws requiring the release of information from
Social Security records (e.g., to t e Government Accountability Office and Department of Veterans'
Affairs), to make determinations or eligibility in similar health and income maintenance programs at the Federal,
State, and local level, and to facilit te statistical research and audit activities necessary to assure the integrity and
improvement of Social Security pr grams (e.g., to the Bureau of the Census and private concerns under
contract to Social Security).
We may also use the information y
records with records kept by other
programs can be used to establi
benefit programs and for repaymen

u provide in computer matching programs. Matching programs compare our
ederal, State, or local government agencies. Information from these matching
h or verify a person's eligibility for Federally-funded or administered
of payments or delinquent debts under these programs.

Additional information regarding thi form, routine uses of information, and our programs and systems, is available
on-line at www.socjalsecurity.gov r at your local Social Security office.

See Revised PRA
Paperwork Reduction Act State ant - This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by Section 2 of the
rw rk Re ucti
995 . You do not need to answer these questions
unless we display a valid Office f Management and Budget control number. We estimate that it will take about
10.5 to 15.5 minutes to read th instructions, gather the facts, and answer the questions. SEND OR BRING

THE COMPLETED F RM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can f"md your loca Social Security office through SSA's website at
www .socialsecuri . o • Offices are also listed under U. S. Government agencies in
your telephone directo y or you may call Social Security at 1-800-772-1213 (TTY 1. 800-325-0778). You ma send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore MD 21235-6401. Send onlv comments relating to our time
estimate to this address, not the completed form.

Form SSA-4-BK (12-201 0) EF (12-201 )

Page 7

RECEIPT FOR YOU

CLAIM FOR SOCIAL SECURITY CHILD'S INSURANCE BENEFITS

BEFORE YOU RECEIVE A
NOTICE OFt WARD

TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO REPORT

(AREA

SSA OFFICE

DATE CLAIM RECEIVED

em E)

AFTER YOU

ECEIVE A

NOTICE OF A WARD

(AREA

COc E)

Your application for Social Security bene its on behalf of the
child(ren) named below has been recE ived. You will be
notified by mail as soon as a decision is nade on your claim.
You should hear from us within
days after you
have given us all the information we reqt ested. Some claims
may take longer if additional information s needed.

lnthe meantime, if you or any child(ren) changes address, or i f
there is 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.
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.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

WORKER'S NAME (If surname differs from name of c imant(s).)

CH ~NGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN pVERPAYMENTS THAT MUST BE REPAID AND IN POSSIBLE MONETARY PENALTIES
~ You or any child changes mailing address f pr checks or residence.

(To avoid delay in receipt of checks y u should ALSO file a
regular change of address notice with your post office.)

~ ~;tchild-,;. 13 ~de~ a~satis~warra~or a

~vi
~

~ Any child's citizenship or immigration statL s changes.
~ Any beneficiary goes outside the U.S.A. fo 30 consecutive days

or longer.
Any beneficiary dies or becomes unable to
~
~

~andle

~

benefits.

Work Changes - On your apphcat1on you t ld us

tion

robat'

or a le

er Fe

r

or St

law.

• •
A student, age 18 or over, stops attending school, reduces
school attendance below full-time, changes schools, or is paid
by an employer to attend school.
If the worker and stepchild's parent divorce. Benefits are not
payable to a stepchild beginning with the month after the
month the worker and the stepchild's parent divorce. Promptly
return any benefit payment received on behalf of the stepchild
for the months after the month the divorce becomes final.

(Name of Child)

~ Change in Marital Status - Marriage, divorce, or annulment of

to be $ - - - - - (Name of Child)

more than

D

0

rendering substantial services in a trade or b
(Report AT ONCE if this work pattern chang s.)

An agency in your State that works with us in
administering the Social Security disability program is
responsible for making the disability decision on the
child's claim. In some cases, it is necessary for them to
get additional information about the child's condition or
to arrange for the child to have a medical examination at
Government expense.

arrant f~ir arrest
y (or in jur ictions
at is pu
able by
1 ear).
Form SSA-4-BK (12-2010) EF (12-2010)

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Page 8

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marriage. You must report marriage even if you believe that an
exception applies.
~ Disability Applicants
In addition to the applicable reporting requirements listed
above:
1 . The disabled adult child returns to work (as an
employee or self-employed) regardless of amount of
earnings.
2. The disabled adult child's condition improves.

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The child age 13 or older h s an unsatisfied warrant for more than 30 days for his or her arrest,
or a crime or attempted cri e that is a felony of flight to avoid prosecution or confinement,
escape from custody and fl" ht-escape. In most jurisdictions that do not classify crimes as
felonies, a crime that is p ·shable by death or imprisonment for a term exceeding one year

~

The child age 13 or older h for more than 30 continuous days committed a violation of
probation or parole under F deral or State law

~

The child is confined form re than 30 continuous days to a jail, prison, penal institution or
correctional facility for con iction of a crime or confined to a public institution by a court order
in connection with a crime.

HOW TO REPORT
You can make your reports by telepho e, 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:

~ Visiting the section "What You C n Do Online" at our web site at www.socialsecurity.gov;
~ Calling us TOLL FREE at 1-800-7 2-1213;

~ If you are deaf or hearing impaire , calling us TOLL FREE at TTY 1-800-325-0778; or

~ Calling, visiting or writing your Ia I Social Security office at the phone number and address above.
For general information about Social S curity, visit our web site at www.socialsecurity.gov.
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 n which the child earns more than the annual exempt amount. You may contact
SSA to file a report for the child. Othe wise, SSA will use the earnings reported by the child's employer(s) and the
child's self-employment tax return (if a plicable) as the report of earnings required by law, to adjust benefits under the
earnings test. It is your responsibility t ensure that the information you give concerning the child's earnings is correct.

Form SSA-4-BK (12-2010) EF (12-2010)

Page 9

SSA will insert the following revised Privacy Act Statement Statement into the
form at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
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 for monthly
benefits or insurance coverage.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed, or could result in
the loss of benefits.
We rarely use the information you supply us for any purpose other than to make a determination
regarding eligibility for monthly benefits and authorize payments to the child or children of
living or deceased workers. However, we may use it for the administration and integrity of our
programs. We may also disclose the information to another person or to another agency in
accordance with approved routine uses, including but not limited to the following:
1. To enable a third party or agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our 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 our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
We also may use the information you give us in computer matching programs. Matching
programs compare our records with records kept by other Federal, State and local government
agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses of the information you provided us is available in our Systems of
Records Notices entitled, Claims Folder System, 60-0089 and Medicare Database (MDB) File,
60-0321. Additional information about these and other system of records notices and our
programs are available online 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. We estimate that it will take about
12 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 21235-0001.