Report of Death by Funeral Director

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 202 of the Social Security Act and Sections 20 CFR 404.715 and 20 CFR 404.720 of the
Code of Federal Regulations allows us to collect this information. Furnishing us this information
is voluntary. However, failing to provide all or part of the information may delay accurate and
timely determinations concerning the death of the individual named, and survivors who may be
eligible for Social Security benefits.
We will use the information to establish proof of death for the insured worker; to determine if the
insured individual was receiving any pre-death benefits SSA needs to terminate; and to
determine which surviving family member is eligible for the lump-sum death payment or other
death benefits. We may also share your information for the following purposes, called routine
uses:
1. To applicants or claimants, prospective applicants or claimants (other than the data
subject), their authorized representatives or representative payees to the extent necessary
to pursue Social Security claims, and to representative payees, when the information
pertains to individuals for whom they serve as representative payees, for the purpose of
assisting the Social Security Administration in administering its representative payment
responsibilities under the Act and assisting the representative payees in performing their
duties as payees, including receiving and accounting for benefits for individuals for
whom they serve as payees.
2. To a State Bureau of Vital Statistics (BVS) that is authorized by States to issue electronic
death reports when the State BVS requests that we verify the SSN of a person on whom
the State will file an electronic death report after we verify the SSN.
3. To the Department of the Treasury to prepare Supplemental Security Income (SSI),
Energy Assistance, and Special Veterans Benefits (SVB) checks to be sent to claimants
or beneficiaries.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0058, Master Files of Social Security Number (SSN) Holders and SSN Applications;
60-0090, Master Beneficiary Record; and 60-0103, Supplemental Security Income Record and
Special Veterans Benefits. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.

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 4 minutes to read the instructions, gather the
facts, and answer the questions. SEND 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.