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

Application for Child's Insurance Benefits

screens for ssa-4 (3)

Application for Child's Insurance Benefits / Life Claim / MCS and PCS

OMB: 0960-0010

Document [doc]
Download: doc | pdf

MCS 3.7                     CHILD'S IDENTIFICATION 1              CHD1

   NH  SSSSSSSSS   SSSSS SSSSSSSSSS         CL  SSSSSSSSS    SSSSS SSSSSSSSSS

[1-C]                          [2-C]                [3-C]

BIRTH CITY: XXXXXXXXXXXXXXX    BIRTH STATE: XX      BIRTH COUNTRY: XX

[4-M]

HAS ANYONE EVER FILED ON CHILD'S BEHALF FOR BENEFITS (Y/N) X

[5-C]

IF YES, NH FIRST NAME: XXXXXXXXXXXXXXX  MI: X  LAST: XXXXXXXXXXXXXXXXXXXX

[6-C]                       [7-C]

NH SSN: XXXXXXXXX     STAT: XX

[8-C]

IF AGE 16 OR OLDER, LANGUAGE SPOKEN AND WRITTEN IS ENGLISH (Y/N):  P

[9-C]

IF OVER 16 IS CHILD DISABLED (Y/N): X

[10-C]

FILING AS DISABLED CHILD ON THIS ACCOUNT (Y/N): X

[11-C]

IF YES, ONSET DATE: 99999999

[12-C]

WILL MEDICARE APPLY:  9  1. YES  2. NO  3. ALREADY ENROLLED

[13-C]

IF ALREADY ENROLLED, SSN:  999999999

 

[14-M]

SELECT FILED OR INTEND TO FILE FOR SSI: 9

   1. YES

   2. NOT DISABlED, BLIND, OR WITHIN 2 MONTHS OF AGE 65 OR OLDER

   3. DOES NOT WISH TO FILE

[15-C]

IF AGE 17 AND 6 MONTHS, IS CHILD A STUDENT (Y/N) X

[16-M]   

WORK LAST YEAR THIS YEAR NEXT YEAR (Y/N): X

[17-M]

EVER MARRIED   (Y/N): X

                                                TRANSFER TO: XXXX

COMM                         child relationship                          cRel

[1-D]                           [2-D]                              [3-D]   

NH:  SSSSSSSSS SSSSS SSSSSSSSSS   BN:  SSSSSSSSS SSSSS SSSSSSSSSS       PIC: SSS

BIRTH CITY: SSSSSSSSSSSSSSS      BIRTH STATE:  SS            BIRTH COUNTRY:  SS      

[4-C]                                      

date dependency met (MMDDCCYY): 99999999

[5-M]                                                        [6-M]

*child relationship begin date (mmddccyy): 99999999          *Proof (y/n): x

[7-M]                                     

*Select rElationship type: 9   1=natural legitimate          6=stepchild

                               2=legitimated child           7=stepchild (216K)

                               3=adopted child               8=inheritance rights

                               4=equitably adopted           9=other (216H3)

                               5=grandchild.             

[8-O]                                    

child relationship end dATE (MMDDCCYY): 99999999    

[9-C]

select relationship end reason: 9

1=parent divorced nh          3=prospective annulment of parent marriage – voidable

2=annulment of adoption       4=ab initio annulment of parent marriage- voidable

                              5=ANNULMENT OF PARENT MARRIAGE – VOID

                              6=CHANGE OF RELATIONSHIP.

[10-O]

DELETE THIS OCCURRENCE OF DATA (Y/N): x

[11-O]                                      [12-O]

ADD NEW OCCURRENCE (Y/N): x                 REVIEW PRIOR OCCURRENCES (Y/N): x       

[13-D]                                                     [14-O]

PF1 HELP AVAILABLE                                         TRANSFER TO: XXXX

MCS 3.3  TRANSFER TO: XXXX   CHILD'S IDENTIFICATION 2                    CHD2

 NH  SSSSSSSSS  SSSSS SSSSSSSSSS    CL SSSSSSSSS  SSSSS SSSSSSSSSS

[1-M]

IF NOT LIVING WITH NH ANY OF LAST 13 MTHS OR AT TIME OF DTH SHOW MTHS

  YR:   ALL  O1  02  03  04  05  06  07  08  09  10  11  12

  99    X    X   X   X   X   X   X   X   X   X   X   X   X

  YR:  ALL   01  02  03  04  05  06  07  08  09  10  11  12

  99   X     X   X   X   X   X   X   X   X   X   X   X   X

[2-C]

IF NOT LIVING WITH NH, WAS CHILD LIVING WITH APPLICANT? (Y/N) 

   [3-C]

   IF No CHILD LIVED WITH:

     NAME:    XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

     [4-C]

     ADDRESS 1: XXXXXXXXXXXXXXXXXXXXXX    ADDRESS 2: XXXXXXXXXXXXXXXXXXXXXX

     ADDRESS 3: XXXXXXXXXXXXXXXXXXXXXX    ADDRESS 4: XXXXXXXXXXXXXXXXXXXXXX

 [5-C]

 IF ADOPTED, NAME OF PERSON ADOPTING IF OTHER THAN NH:

  FIRST: XXXXXXXXXX MI: X   LAST: XXXXXXXXXXXXXXXXXXX

MCS 3.7                     CHILD’S POTENTIAL ENTITLEMENT           CHPE

    NH SSSSSSSSS    SSSSS  SSSSSSSSSS       CL SSSSSSSSS    SSSS  SSSSSSSSSS

[1-M]

CHILD POTENTIALLY ENTITLED ON ADOPTIVE, STEP OR OTHER PARENT RECORD (Y/N): X

[2-M]

CHILD POTENTIALLY ENTITLED ON A GRAND OR STEP GRANDPARENT RECORD (Y/N): X

LIST THE NAME AND SSN CHILD POTENTIALLY ENTITLED

   [3-C]                                     [4-C]

   FIRST NAME       MI LAST NAME             SSN

   XXXXXXXXXXXXXXX  X  XXXXXXXXXXXXXXXXXXXX  XXXXXXXXX

   XXXXXXXXXXXXXXX  X  XXXXXXXXXXXXXXXXXXXX  XXXXXXXXX

   XXXXXXXXXXXXXXX  X  XXXXXXXXXXXXXXXXXXXX  XXXXXXXXX

   XXXXXXXXXXXXXXX  X  XXXXXXXXXXXXXXXXXXXX  XXXXXXXXX

   XXXXXXXXXXXXXXX  X  XXXXXXXXXXXXXXXXXXXX  XXXXXXXXX

                                                                TRANFER TO: XXXX

MCS 2.5  TRANSFER TO:  XXXX   DEPENDENT CHILDREN OF NH       DEPC

NH  SSSSSSSSS    SSSSS SSSSSSSSSS   CL  SSSSSSSSS SSSSS SSSSSSSSSS

LIST ALL CHILDREN OF NH:    UNDER 18

                            18-19 AND ATTENDING SECONDARY SCHOOL

[1-M]        DISABLED/HANDICAPPED PRIOR TO 22

NAME:

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

    XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

COMM                   CITIZENSHIP (U.S. AND/OR FOREIGN)                        CLCZ

[1-D]                               [2-D]                                       [3-D]

NH:  SSSSSSSSS SSSSS SSSSSSSSSS     BN:  SSSSSSSSS SSSSS SSSSSSSSSS             PIC: SSS            

[4-M]

*COUNTRY/TERRITORY OF CITIZENSHIP: xx                   

   [5-C]

   SELECT U.S. TYPE IF CITIZENSHIP COUNTRY IS U.S.: 9

   1= BIRTH IN U.S.   2= U.S. CITIZEN BORN OUTSIDE U.S.   3= NATURALIZATION

   [6-C]

   SELECT U.S. PROOF IF CITIZENSHIP COUNTRY IS U.S.: 9

   1= ENUMERATION        4=DEVELOPMENT PENDING

   2= TITLE 2/18/16      5=NO PROOF

   3= FUTURE USE         6=PRESUMED - SYSTEMS GENERATED ONLY      

[7-M]

*CITIZENSHIP START DATE (MMDDCCYY): 999999999

[8-O]

CITIZENSHIP STOP DATE (MMDDCCYY): 999999999

[9-O]

IS LAWFUL PRESENCE DATA NEEDED (Y/N): X

[10-O]

DELETE THIS OCCURRENCE OF DATA (Y/N): X

[11-O]                                                 [12-O]

ADD NEW OCCURRENCE (Y/N): X                            REVIEW PRIOR OCCURRENCES (Y/N): X

[13-D]                                                 [14-O]

PF1 HELP AVAILABLE                                     TRANSFER TO: XXXX

MCS                         CLAIMANT MAILING ADDRESS                  CADR

NH: SSSSSSSSS SSSSS SSSSSSSSSS           CL: SSSSSSSSS SSSSS SSSSSSSSSS

 [1-M]

 *ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP           ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP

 ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP           ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP

[2-M]                                     [3-C]             [4-C]

*CITY: PPPPPPPPPPPPPPPPPPPPPP             STATE:  PP        ZIP:  PPPPP

[5-C]                                            [6-C]

STATE & COUNTY CODE: PPPPP                       COUNTY: XXXXXXXXXXXXXX

[7-C]                                                 [8-C]

COUNTRY: PPPPPPPPPPPPPPPPPPPPP                        CONSULAR CODE: PPP

[9-C]

FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

[10-M]                                       [11-M]

*bank account (y/n): x                       *direct express (y/N): x

[12-C]                                                   [13-C]

DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999         ACCOUNT TYPE (C/S): A

[14-C]

DEPOSITOR ACCOUNT NUMBER: 99999999999999999

[15-C]                                      [16-C]

DOMESTIC PHONE: PPPPPPPPPP                  FOREIGN PHONE: PPPPPPPPPPPPPPP

[17-c] 

enter phone code: x  1= home 2= work 3=none 4=unknown 5=other 6=attorney 7=mobile

TRANSFER TO: XXXX        CLIENT ADDRESS                       CLAD

                                    SS SSSSSSSSS     SSSSS SSSSSSSSSS

[1-D]

ADDRESS TYPE:  SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

[2-C]

ADDRESS:  PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

          PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

   [3-C]                         [4-C]        [5-C]

   CITY:  PPPPPPPPPPPPPPPPPPP    STATE: PP    ZIP:PPPPP

[6-C]                       [7-M]

STATE/COUNTY CODE: PPPPPP   DISTRICT OFFICE CODE: PPP

[8-C]                                    [9-C]

FOREIGN COUNTRY: PPPPPPPPPPPPPPPPPPPPPPP FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

  [10-C]               [11-C]

  CONSULAR CODE: PPP   GEOGRAPHIC CODE: PPPPP

[12-M]    [13-C]   [14-C]

START     END      N/E

(MMDDYY)  (MMDDYY)

 PPPPPP    PPPPPP    X

[15-M]          [16-M]                       [17-M]                  [18-D]

NEW (Y/N): X    DELETE THIS PAGE (Y/N): X    EXIT CLAD (Y/N): X      SS OF SS

MCS       TRANSFER TO: XXXX   REMARKS SCREEN                           RMKS

  NH SSSSSSSSS    SSSSS SSSSSSSSSS    CL  SSSSSSSSS   SSSSS  SSSSSSSSSS

[1-C]

TYPE OF REMARKS

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[2-C]                        [3-C]

MORE (Y/N): X                GO TO RPS (Y/N): X

                                        PAGE S


File Typeapplication/msword
File TitleMCS 3
Author084680
Last Modified By889123
File Modified2010-03-02
File Created2010-03-02

© 2024 OMB.report | Privacy Policy