Form SSA-721 Statement of Death by Funeral Director

Form Approved
0MB No. 0960-0142

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF DEATH BY FUNERAL DIRECTOR
SOCIAL SECURITY NUMBER

NAME OF DECEASED

I

FOR SSA USE ONLY

7

L

Please complete the items below, and return the
form in the enclosed addressed, postage paid
envelope. Your assistance and cooperation are
appreciated.

_J

PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the Federal
While your response is voluntary, we need your assistance to make an accurate and timely
Regulations (20 CFR 404.715 and 404.720).
determination concerning the death of the individual named above. and to detennine if there are survivors who may be eligible for Social
Security benefits.
We may also use the infonnation 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.
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 3.5 minutes to read the instructions. gather the facts. and answer the questions. SEND 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 lime estimate
above to: SSA, 6./01 Security Blvd.. Baltimore. MD 2/235-640/. Send 011/11 commellts relating to our time estimate to tltis address, 11ot the
completed form.
12. * SOCIAL SECURITY NUMBER
iIf SSN Unknown, please contact
Field office to report death.

1. * NAME OF DECEASED (First, Middle, Last, Suffix)
1a. other names used, (if known)
3. * DATE OF DEATH
3a *City/State/Country
(Where death occurred)

5. * Check (x) whether the deceased was
O Male
OFemale

4. * DATE OF BIRTH (if known)
4a City/State/Country

6. NAME OF Surviving Spouse WIDOW OR WIDOWER (if known) if not
applicable, names of any minor or disabled children, (if known)”.
6a. Surviving Spouse SSN.

7. ADDRESS (No. and Street, P.O. Box) OF Surviving Spouse WIDOW OR
WIDOWER (if known) f not applicable, names of any minor or disabled
children, (if known)”.
CITY
STATE
ZIP CODE

TELEPHONE NUMBER (if Available)

)

(
area code

I hereby certify that I am an authorized funeral director and prepared for final disposition the body of the person named above. I understand
this statement may be used in connection with an application for Social Security benefits. 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.

*NAME AND ADDRESS OF FUNERAL DIRECTOR OR FIRM

*SIGNATURE OF FUNERAL DIRECTOR OR
AUTHORIZED REPRESENTATIVE
*TELEPHONE

ro

(___)
NUMBER
area code
FOR SOCIAL SECURITY USE ONLY - DO NOT WRITE IN THIS SPACE

Processed (Date)

Form SSA-721 (5-2005) ef (8-2008) Use 1-2004 edition until supply is exhausted

*DATE

A MESSAGE FROM SOCIAL SECURITY

Your funeral director is helping the Social Security Administration office by providing giving
you this information about Social Security benefits. If the deceased was receiving benefits, you
need to contact us to report the death. If you think you may be eligible for survivors benefits,
you should contact us to apply.
HOW SOCIAL SECURITY HELPS FAMILIES

Social Security survivors benefits help ease the financial burden that follows a worker's death.
Almost all children under age 18 will receive get monthly benefits if a working parent dies.
Other family members may be eligible for benefits, too.
Anyone who has worked and paid Social Security Federal Insurance Contributions Act
(FICA) taxes has been earning Social Security benefits for his or her family. The amount of
work needed to pay survivors benefits depends on the worker's age at the time of death. It may
be as little as 1 to 1.5-1/2 years for a young worker. No one needs more than 10 years.
WHO CAN GET SURVIVORS BENEFITS?

Here is a list of family members who are typically eligible for usually can get benefits:
• Surviving spouses Widows and widowers age 60 or older.
• Surviving spouses Widows and widowers at any age if caring for the
deceased's child(ren) who are under age 16 or disabled.
• Divorced spouses wives and husbands age 60 or older, if married to the
deceased
10 years or more.
• Surviving spouses and divorced spouses Widows, widowers, divorced wives,
and divorced husbands age 50 or older, if they are disabled.
• Children up to age 18.
• Children age 18 - 19, if they attend elementary school or high school full time.
• Children over age 18, if they became disabled before age 22.
• The deceased worker's parents age 62 or older, if they were being supported
by the worker.
A SPECIAL ONE-TIME PAYMENT

In addition to the monthly benefits for family members, a one-time lump-sum death payment of
$255 can be paid to a spouse who was living with the worker at the time of death. If there is
none, it can be paid to:
• A spouse who is eligible for benefits.
• A child or children eligible for benefits.
This payment cannot be made if there is no eligible spouse or child.
HOW TO APPLY FOR BENEFITS

How you sign up for Social Security benefits depends on whether or not you are receiving
getting other Social Security benefits.
If you aren't receiving getting Social Security benefits, you can apply for benefits by
telephone, by accessing the Social Security website www.socialsecurity.gov, or by going to
any local Social Security office. You may need some of the documents shown on the list
below. But don't Do not delay your application because you do not don't have all the
information. If you don't do not have a document you need, the Social Security Administration
can help you obtain get it.
Form SSA-721 (5-2005) ef (8-2008)

HOW TO APPLY FOR BENEFITS (continued)

In many situations, Iif you're already getting benefits as a spouse wife or husband on your
spouse's record when they pass away he or she dies, in many situations we can automatically
change your payments to survivors benefits once the death is reported to us . you report the
death to us. Benefits for any children will also automatically be changed to survivors benefits
once after the death is reported to us.
INFORMATION NEEDED
• Your Social Security number and the deceased worker's Social Security number.
• A death certificate. (Generally, the funeral director provides a statement that can be used for this
purpose.)
• Proof of the deceased worker's earnings for the previous last year (W-2 forms or self- employment tax
return).
• Your birth certificate.
• A marriage certificate, if you are applying for benefits as a surviving spouse widow, widower,
divorced spouse wife, or divorced husband.
• A divorce decree, if you are applying for benefits as a divorced spouse wife or
husband.
• Children's birth certificates and Social Security numbers, if applying for
children's benefits.
• Your checking or savings account information, for if you want direct deposit of
benefits.
your
to submit original documents or copies certified by the custodian of records
need
You will
issuing office. You can mail or bring them to the office. Social Security will make photocopies
and return the documents to you. your
documents.
SUPPLEMENTAL SECURITY INCOME (SSI)

If you are 65 or older, disabled, or blind, and have limited income and resources ask the Social
Security representative about
Supplemental Security Income (SSI) checks for people with limited income and resources. If
you receive SSI, you may also qualify for Medicaid, Supplemental Nutrition Assistance
Program (SNAP) food stamps, and other social services.
FOR MORE INFORMATION

For more information, visit Social Security's website at www.socialsecurity.gov. You can also
phone the toll-free number at 1-800-772-1213 (TTY 1-800-325-0778). By calling the 800
Number, you can use our automated telephone services to get recorded information and
conduct some business 24 hours a day. You can speak to a Social Security representative
between 7 a.m. and 7 p.m. Monday through Friday.You can also write or visit any Social Security
office. To find your local office, visit our Social Security Office Locator at
www.socialsecurity.gov., or phone the toll-free number, 1-800-772-1213. You can speak to a
representative weekdays 7 a.m. to 7 p.m. You can also
visit Social Security's Internet website: www.socialsecurity.gov.
A REMINDER
If the deceased received was receiving Social Security benefits, return any checks, which arrive after death to the Social Security
office. If Social Security checks were being directly deposited into a bank account, please notify the bank of the death.

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, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely determination concerning eligibility for death
benefit payments.
We will use the information you provide to establish proof of death for the insured worker; to
determine if the insured individual was receiving any pre-death benefits we need 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 the information for the following purposes, called
routine uses:
•

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 payees in performing their duties as payees, including receiving and
accounting for benefits for individuals for whom they serve as payees; and

•

To Federal, State, or local agencies (or agents on their behalf), for administering
income or health maintenance programs including programs under the Social Security
Act.

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 Notices
(SORN) 60-0058, Master Files of Social Security Number (SSN) Holders and SSN Applications,
as published in the Federal Register (FR) on December 29, 2010, at 75 FR 82121; 60-0090,
Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and 600103, Supplemental Security Income Record and Special Veterans Benefits, as published in the
FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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
4 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.