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

MCS 3.7                     CHILD'S IDENTIFICATION 1              CHD1

   NH  SSSSSSSSS   SSSSS SSSSSSSSSS         CL  SSSSSSSSS    SSSSS SSSSSSSSSS

BIRTH CITY: XXXXXXXXXXXXXX    BIRTH STATE: XX      BIRTH COUNTRY: XX

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

IF YES, NH FIRST NAME: XXXXXXXXXXXXXX  MI: X  LAST: XXXXXXXXXXXXX

NH SSN: XXXXXXXXX     STAT: XX

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

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

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

IF YES, ONSET DATE: 99999999

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

IF ALREADY ENROLLED, SSN:  999999999

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

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

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

EVER MARRIED   (Y/N): X

                                                TRANSFER TO: XXXX

COMM CHILD RELATIONSHIP CREL

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

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

DATE DEPENDENCY MET (MMDDCCYY): 99999999

*CHILD RELATIONSHIP BEGIN DATE (MMDDCCYY): 99999999 *PROOF (Y/N): X

*SELECT RELATIONSHIP TYPE: 9 0=STATE INTESTACY LAW 5=GRANDCHILD

1=NATURAL LEGITIMATE 6=STEPCHILD

2=LEGITIMATED CHILD 7=STEPCHILD (216K)

3=ADOPTED CHILD 8=INHERITANCE RIGHTS

4=EQUITABLY ADOPTED 9=OTHER (216H3).

CHILD RELATIONSHIP END DATE (MMDDCCYY): 99999999

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 IN RELATIONSHIP.

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

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

PF1 HELP AVAILABLE TRANSFER TO: XXXX

MCS 3.3 CHILD'S IDENTIFICATION 2 CHD2

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

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

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

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

IF NOT LIVING WITH NH (AS SHOWN ABOVE),

WAS CHILD LIVING WITH APPLICANT? (Y/N): A

IF NO, CHILD LIVED WITH:

NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX REL: AAAAAAAAAA

ADDRESS 1: XXXXXXXXXXXXXXXXXXX ADDRESS 2: XXXXXXXXXXXXXXXXXXX

ADDRESS 3: XXXXXXXXXXXXXXXXXXX ADDRESS 4: XXXXXXXXXXXXXXXXXXX

IF ADOPTED, NAME OF PERSON ADOPTING IF OTHER THAN NH

FIRST: XXXXXXXXXX MI: X LAST: XXXXXXXXXXXXXXXXXXX

 

TRANSFER TO: XXXX

MCS 3.7                     CHILD’S POTENTIAL ENTITLEMENT  CHPE

    NH SSSSSSSSS    SSSSS  SSSSSSSSSS       CL SSSSSSSSS    SSSS  SSSSSSSSSS

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

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

LIST THE NAME AND SSN CHILD POTENTIALLY ENTITLED

   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

  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

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

*COUNTRY/TERRITORY OF CITIZENSHIP: XX                   

   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

   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      

*CITIZENSHIP START DATE (MMDDCCYY): 999999999

CITIZENSHIP STOP DATE (MMDDCCYY): 999999999

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

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

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

PF1 HELP AVAILABLE                                     TRANSFER TO: XXXX

MCS                          CLAIMANT MAILING ADDRESS                  CADR

NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP

ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP

*CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP

STATE & COUNTY CODE: PPPPP COUNTY: XXXXXXXXXXXXXX

COUNTRY: PPPPPPPPPPPPPPPPPPPPP CONSULAR CODE: PPP

FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

*BANK ACCOUNT (Y/N): X *DIRECT EXPRESS (Y/N): X

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

DEPOSITOR ACCOUNT NUMBER: 99999999999999999

DOMESTIC PHONE: PPPPPPPPPP FOREIGN PHONE: PPPPPPPPPPPPPPP

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

ADDRESS TYPE:  SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

ADDRESS:  PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

          PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

     CITY:  PPPPPPPPPPPPPPPPPPP    STATE: PP    ZIP:PPPPP

STATE/COUNTY CODE: PPPPPP   DISTRICT OFFICE CODE: PPP

FOREIGN COUNTRY: PPPPPPPPPPPPPPPPPPPPPPP FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

  CONSULAR CODE: PPP   GEOGRAPHIC CODE: PPPPP

START     END      N/E

(MMDDYY)  (MMDDYY)

 PPPPPP    PPPPPP    X

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

TYPE OF REMARKS

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

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