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Fillable Printable Form SSA-5-BK

Fillable Printable Form SSA-5-BK

Form SSA-5-BK

Form SSA-5-BK

Has an unmarried child or dependent grandchild of the deceased, who is under age 16 or disabled, lived with you any
time from the month of death through the present month? (This includes adopted child, stepchild, and stepgrandchild.)
(If "Yes," enter the information requested below.)
FemaleMale
(Do not write in this space)
TOE 120/145/155
Form Approved
OMB No. 0960-0003
APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*
With this application, you are applying for all insurance benefits for which you are eligible
under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII
(Health Insurance for the Aged and Disabled) of the Social Security Act, as presently
amended. The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment.
*This may also be considered an application for survivors 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 benefits
under Title 38).
1.(a) PRINT name of deceased wage earner or self-employed
person (herein referred to as the "deceased").
(b) Check (X) one for the deceased.
(c) Enter deceased's Social Security Number.
2.(a) PRINT your name.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter your Social Security Number.
3.Enter your name at birth if different from item 2(a).
4.
(a) Enter your date of birth.
MONTH, DAY, YEAR
(b) Enter name of State or foreign country where
you were born.
You may receive a mother's or a father's benefit for any month in which you have in your care the deceased's child or
dependent grandchild who is entitled to a child's benefit if the child is:
under age 16,
or disabled or handicapped (age 16 or over and disability began before age 22).
If you are filing as a surviving divorced mother or father, the child must be your son, daughter, or legally adopted child who
is entitled to child's benefits on the deceased's earnings record.
Mother's or father's benefits are not payable if the only child in your care is a child age 16 or over who is not disabled.
PLEASE READ CAREFULLY BEFORE ANSWERING ITEM 5
Form SSA-5-BK (05-2015) UF (05-2015)
Destroy Prior Editions
Page 1
5.
Name of child
Months and Year child lived with you (If all, write "ALL")
Social Security Administration
TEL
FIRST NAME, MIDDLE INITIAL, LAST NAME
YesNo
Form SSA-5-BK (05-2015) UF (05-2015)
Marriage performed by:
Spouse's Social Security Number (If none or unknown, so indicate)
Page 2
(a) Have you (or has someone on your behalf) ever filed an
application for
Social Security benefits, a period of disability under Social Security,
Supplemental Security Income, or hospital or medical insurance under
Medicare?
Is there a surviving parent (or parents) of the deceased who was receiving
support from the deceased at the time of death or at the time the deceased
became disabled?
INFORMATION ON YOUR MARRIAGE(S)
(a) Enter information about your marriage to the deceased.
(b) If "Yes," list the country(ies).
10.
(If "Yes," enter the name and address of
the parent(s) in "Remarks" on page 5.)
11.
Spouse's Name (including maiden name)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)Where (Name of City and State)
Marriage performed by:
Date of death
Clergyman or public official
Other (Explain in "Remarks")
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)
Spouse's Name (including maiden name)
When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Spouse's date of birth (or age)
(If "No," go on to
item 7.)
(If "Yes," answer
(b) and (c).)
(b) Enter name of person(s) on whose Social Security record
you filed other application.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter Social Security Number of person named in (b).
(If unknown, so indicate.)
7.(a) Are you, or during the past 14 months have you been, unable to work
because of illnesses, injuries or conditions?
(If "Yes,"
answer (b).)
(If "No," go on
to item 8.)
MONTH, DAY, YEAR
(b) Enter the date you became unable to work.
8.Did you work in the railroad industry for 5 years or more?
9.(a)
Do you have Social Security credits (for example, based on work or
residence) under another country's Social Security system?
(If "No," go on
to item 10.)
(If "Yes,"
answer (b).)
(b) If you remarried after the marriage shown in 11. (a), enter information about the last marriage.
(If none, write "NONE".)
6.
(c) If you had other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether
before or after you married the deceased), enter the information below. If you divorced then remarried the same
individual within the year immediately following the year of the divorce, and the combined period of marriage totaled
10 years or more, include the marriage. (If none, write "NONE".)
NoYes
NoYes
NoYes
NoYes
NoYes
Spouse's date of birth (or age)
Other (Explain in "Remarks")
Clergyman or public official
You
Marriage performed by:
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
12.
Spouse's Name (including maiden name)
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Marriage performed by:
Spouse's date of birth (or age)
Spouse's Name (including maiden name)
Date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Marriage performed by:
Spouse's date of birth (or age)
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
Spouse's Social Security Number (If none or unknown, so indicate)
(b) Enter information about any other marriage the deceased may have had that lasted at least 10 years (see item
11. (c) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse
(whether before or after you married the deceased). Do not include the marriage to you.
(If none, write "NONE".)
Spouse's Social Security Number (If none or unknown, so indicate)
INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)
Answer this item ONLY if the deceased had other marriages.
(a) If the deceased married after his or her marriage to you, enter the information on the last marriage.
(If none, write
"NONE".)
Spouse's Social Security Number (If none or unknown, so indicate)
Form SSA-5-BK (05-2015) UF (05-2015)Page 3
Spouse's Name (including maiden name)
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Spouse's date of birth (or age)
13.(a) Were you and the deceased living together at the same address when the
deceased died?
(If "No,"
answer (b).)
(If "Yes," skip to
item 14.)
Who was away?
Reason absence began
IF YOU ARE APPLYING FOR SURVIVING DIVORCED
SPOUSE'S
BENEFITS, SKIP ITEM 13 AND GO ON TO ITEM 14.
(b)
If either you or the deceased were away from home (whether or not temporarily) when the deceased died,
give the following:
Date last at home
Other (Explain in "Remarks")
Clergyman or public official
Other (Explain in "Remarks")
Clergyman or public official
Other (Explain in "Remarks")
Clergyman or public official
No
Yes
Deceased
(b)
I receive a government pension or annuity.
I applied for and am awaiting a decision on my pension or lump sum.
Check if applicable:
Year
No
Yes
Reason you were apart at time of death
If separated because of illness, enter nature of illness or
disabling condition
ANSWER ITEM 14 ONLY IF THE DECEASED DIED BEFORE THIS YEAR. OTHERWISE, GO ON TO ITEM 15.
14.
(b) Place an "X" in each block for EACH MONTH of last year in which you did not
earn more than *$ in wages, and did not perform substantial services
in self-employment. These months are exempt months. If no months were exempt
months, place an "X" in "NONE". If all months were exempt months, place an "X"
in "ALL."
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings
Affect Your Benefits".
NONE
MAR
MAYJULAUG
SEPTOCTNOVDEC
FEBJAN
ALL
JUN
(a) How much were your total earnings last year?
$
Form SSA-5-BK (05-2015) UF (05-2015)Page 4(Turn to Page 5)
(b) Place an "X" in each block for EACH MONTH of this year in which you did not or
will not earn more than *$ in wages, and did not or will not perform
substantial services in self-employment. These months are exempt months. If no
months are or will be exempt months, place an "X" in "NONE". If all months are or
will be exempt months, place an "X" in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings
Affect Your Benefits".
ANSWER ITEM 16 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT., OCT., NOV.,
AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR). OTHERWISE, GO ON TO ITEM 17.
If you use a fiscal year, that is, a taxable year that does not end
December 31
(with income tax return due April 15), enter here the month your fiscal year ends.
MONTH
16.
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
expect to earn more than *$ in wages, and do not expect to perform
substantial services in self-employment. These months will be exempt months. If
no months are expected to be exempt months, place an "X" in "NONE". If all
months are expected to be exempt months, place an "X" in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".
(a) How much do you expect to earn next year?
$
15.(a) How much do you expect your total earnings to be this year? $
(If "Yes," check
the box in item (b)
that applies.)
I received a lump sum in place of a government pension
or annuity.
Month
I have not applied for but I expect to
begin receiving my pension or
annuity: (If the date is not known,
enter "Unknown.")
17.
(a) Have you qualified for, or do you expect to qualify for, a pension or
annuity (or a lump sum in place of a pension or annuity) based on
your own employment and earnings for the Federal Government of
the United States, or one of its States or local subdivisions? (Social
Security benefits are not government pensions).
(If "No," go on, to
item 18.)
18.
I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand
that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid
with full retroactivity.
APR
NONE
MAR
MAYJULAUG
SEPTOCTNOVDEC
FEBJAN
ALL
JUN
APR
NONE
MAR
MAYJULAUG
SEPTOCTNOVDEC
FEBJAN
ALL
JUN
APR
Direct Deposit Refused
Enroll in Direct Express
Savings
Checking
REMARKS(You may use this space for any explanations. If you need more space, attach a separate sheet.)
Form SSA-5-BK (05-2015) UF (05-2015)Page 5
Direct Deposit Payment Address (Financial Institution)
Account Number
Date (Month, Day, Year)
Telephone number(s) at which you may be
contacted during the day
AREA CODE
Routing Transit Number
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 statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be subject to a fine or imprisonment.
SIGNATURE OF APPLICANT
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks" on page 5, if different.)
City and StateZIP Code
County (if any) in which you now live
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses. Also, print the
applicant's name in the Signature block.
Address (Number and Street, City, State and ZIP Code)Address (Number and Street, City, State and ZIP Code)
Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN
HERE
1. Signature of Witness2. Signature of Witness
Form SSA-5-BK (05-2015) UF (05-2015)Page 6
-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. The OMB control number for this collection is
0960-0003. We estimate that it will take 15 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 21235-6401.
Privacy Act Statement
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 of you or a dependent for Social Security benefits.
Furnishing us this information is voluntary. However, failure to provide all or part of the information could prevent us from
making an accurate and timely decision on your entitlement or a dependent's entitlement to Social Security benefit
payments.
We rarely use the information you supply for any purpose other than for making a determination relating to your entitlement
or a dependent's entitlement to Social Security benefit payments. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security 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
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. Information from these matching programs can be
used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice entitled, Master Beneficiary
Record, 60-0090. This notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.govor at your local Social Security office.
Paperwork Reduction Act Statement
AFTER YOU RECEIVE
A NOTICE OF AWARD
(AREA CODE)
Your application for Social Security benefits has been
received and will be processed as quickly as possible.
You should hear from us within days after you
have given us all the information we requested. Some
claims may take longer if additional information is needed.
In the meantime, if you change your address, or if
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 calling
about your claim.
If you have any questions about your claim, we will be glad to
help you.
TELEPHONE
NUMBER(S) TO
CALL IF YOU
HAVE A
QUESTION OR
SOMETHING TO
REPORT
SSA OFFICE DATE CLAIM RECEIVED
SOCIAL SECURITY
CLAIM NUMBER
CLAIMAINT
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY MOTHER'S OR FATHER'S INSURANCE BENEFITS
BEFORE YOU RECEIVE
A NOTICE OF AWARD
(AREA CODE)
DECEASED'S SURNAME IF DIFFERENT
FROM CLAIMANT'S
• You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice with
your post office.)
• Your citizenship or immigration status changes.
• You go outside the U.S.A. for 30 consecutive days
or longer.
• Any beneficiary dies or becomes unable to
handle benefits.
• Work Changes - On your application you told us you
expect total earnings for to be $ .
You (are) (are not) earning wages of more than
$ a month.
You (are) (are not) self-employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes.)
• Change of Marital Status - Marriage, divorce, annulment
of marriage. You must report a change in marital status
even if you believe that an exception applies.
• Custody Change or Disability Improves - Report if a
person for whom you are filing, or who is in your care
dies, leaves your care or custody, changes address, or if
disabled, the condition improves.
• You are confined to jail, prison, penal institution or
correctional facility for more than 30 continuous days for a
conviction of a crime or you are confined for more than 30
continuous days to a public institution by a court in
connection with a crime.
• You have an unsatisfied warrant for more than 30
continuous days for your arrest for a crime or attempted
crime that is a felony or flight to avoid prosecution or
confinement, escape from custody, and flight-escape. In
most jurisdictions that do not classify crimes as felonies,
this applies to a crime that is punishable by death or
imprisonment for a term exceeding 1 year (regardless of
the actual sentence imposed).
Form SSA-5-BK (05-2015) UF (05-2015)Page 7
CHANGES TO BE REPORTED AND HOW TO REPORT
• You violated for more than 30 continuous days a condition
of your probation or parole under Federal or State law.
• You begin to receive a government pension or annuity
(from the Federal government or any State or any political
subdivision thereof) or your pension or annuity amount
changes.
WORK AND EARNINGS
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 in which you earn more
than the annual exempt amount. You may contact SSA to file
a report. Otherwise, SSA will use the earnings reported by
your employer(s) and your self-employment tax return (if
applicable) as the report of earnings. It is your responsibility to
ensure that the information you give concerning your earnings
is correct. You must furnish additional information as needed
when your benefit adjustment is not correct based on the
earnings on your record.
HOW TO REPORT
You can make your reports by telephone, 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 Can Do Online" at our
web site at www.socialsecurity.gov;
• Calling us TOLL FREE at 1-800-772-1213;
• If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or
• Calling, visiting or writing your local Social Security
office at the phone number and address shown on
your claim receipt.
For general information about Social Security, visit our web
site at www.socialsecurity.gov.
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST
BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
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