Form SSA-8-F4 Application For Lump-Sum Death Payment

TOE 12?/1#1166

Rrm Approved
OMB NO. W80-0013

AWWATlOlY FOR LUMP-SUM DEATH PAYAIIENP
I apply for all insurance benefits for which I am eligible under Title II (Federal
Old-Age, Survivors, and Disability Insurance) of the Soclal Se~urltyAct, as
presently amended, on the named deceased's Social Security r m r d .
(This application must be filed within 2 years after the date of
death of the wage earner or d f - e m p l o y 4 person,)
TUa may rdso b comtded an appllcatlOn for h r u n c a benefit8 p a y d o
vlder the Railroad Aetlremem Aet ,

.I

1 1.1

PRINT n a m of -ed
~ a g mrnu
a
or Self-Employ4 Person
Owrein referred to as the "deceasedw)

~RRST
NAME, MIDDLE INITIAL, UST NAME

'

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tbl Check (XI one for the deceased

C]m a l e

.I

Ic) Ewer deceased's Social Security Number

FIRST NAME, MIDDLE INITjAL, LAST NAME

2.1

I

PRlW your name

+I

Entw date of birth of deceased

(a)

Did the d e d ever fib an application for Social Security
benefits, a p r b d of d b a b i l i under Swlal Security,
supplemental security income, or laospitat or mdkal
Insurance under Medicare?
+

{b] Enter mmdQ of persods1 on whose
m i a l Security recard(s1 other
applicetlon was flled.

UNOn u n k n o w n

Dyes

(If

"

(If *IVo " Or
go on to item 6.1

1bj and Ic/J

'

FIRST NAME, MIDDLE INITIAL, IAST NAME
›

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Icl Enter Social Security MurnberIs) of person(s) named in {b).

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(If uhknown, so Indicate)
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ANSWER ITEM 8 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.
1 AMOUNT
(. 8.) About how much did the d-ed
earn from wnployment
and self-emplovment during the year of death?
IC
tb)
I AMOUNT
- - .About how much did the deceased earn the yaw bsforar

----

--I

.IS

death?

ANSWER ITIN 7 ONLY IF THE DECEASED DIED PRIOR TO AGE 86 AND WITHIN THE PAST 4 MONTHS,
I

Oy=
Iff 'Yes,'

(a) Was the d e c d unable to work becam of Illness, i n j h
or wnditions at the tlme of death?
(b) Enter the date the deemed became unable to work

I-,

day, year)

(a) W ~ the
B dtmmed In the acthro mliltary or naval earvice

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(including Reserve or National Guard actks duty w a&e
duty for tralnlng) after September 7, 1939 and before 19687

"No," go on
Itm 8.)

to

.-

I
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(If "Yes, " answer
161 and tcl.1
From: (Month, Year)

(b) Enter dates of service.

(If

aursww (61.1

(if "No, " go on
to iten 9.1

To: IMwrarr, Yeerl

•
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(c) Has anyone (including the dgceased) m e i d , or does
anyone eKpect to recdve, a benefit from any other

Fdwal agency?

NO

Dld the deceased work In the railroad
~ndustryfor 7 yem or mom7
8SAaF4 (6-20031

EF (02-2006)

Destroy Prior Ediiow

t

YSS

ONO
Page 1

(a) bld the deceased ever anOager in wwk that W M C O V O ~
unda the social security system of a country other than the
united States?

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II

(lf "Yes," answer lb1.l (f! "No, go on to l t m I 1.1

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(b) If "Yw," list the country{les).

Is the d
e survived by a sgouw or ax-spoutrs? (If "No,' go on to itam 12. If "Yw,"
give the following Information .bwt all nurlagas of the dd.euad incLmD illariafa9 in
effect at time of death.) (If you nsed mora ~ p e c a~ # ~ *1 h
1 m r k ~A
"
on k k page
or m h a ~~4
shsst.1
'a whom married fMnm at

l~ow
rn-

hst
of the
dse-ed

of

dd

If

Rons

yewl

Wtma (&far n#ne of Chy and Stale)

hy,

How rnmlew ended

MwIsga performed by:

a Clergyman or N l c offlclal

]when m~llh
&Y,
When IMrwrth, day,

glva date of &ath

H -deceased,

Number t H n m w rrnknown. so h d h t e l

To whom m d d llllbme at Bhl
Rsviua
rnaniaw

lwhera lbrtermm8 of City andStet8)

M M T a ~ g ~ ~ ~ b y :spw#r'r dote a i birth (or ago)
CWgwmn w pale o m a l
~ o t h s r ~ h & m w k s l
8pwse'a h Y Sw&

ON^

l ~ n e month,
n
dsy, yawl
When I-,

ended

nye

, , , I /

,
,
,
,

]where Ibrtwnsme of CyrmdStatel

&

Whem I-

yebf)

Spouse's dats of Mlth (or age)

mme of City and Statel

ifwouse cbwaeed, glw date of daatj~

D ~ h c l r 1 - k , ~

Thu dsoessed's surviving chltdren (including natural children, adoptad children, and stepchildren) or dependent
grmdchl#rsn (including stopgrendchiIdren) may be eiiglble for bermfits b e a d on the earnings reeord of the
&cemd.
list below A U such ehlldrm who are now or w e in the past 12 months UNMARRIED and:
UNDER AGE 18 AGE 18 TO 19 AND AmNDING SECONDARY SCHOOL
DISABLED OR HANDICAPPED (e
18 or over and dlaaMllty began before age 22)
(Hnonr, wetP. "Nma.")
Full Name of Child
I
Full Name of Chlld

*

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Dyes nM0

Is thsre a sunrhring parent (or param) of the dacemsd who was
mahlng support from the
s b at the tlms the
disabld under the Social Wurity law at the
time of death7
•

tlf

n~ss,w

merthe name a

~ I W M ( S )In "Remarks".)

Have yau flld for any Social Sacurfty bemfitson ths dscsassd's

earnlw rsoord bfm?
NOTE: If-

y-

B

kraauvhbg ~poume,m w i t h h 16. If not, 6kIp hemp 15

of the

d
NO

18.

If you &re not tlw w h r f n g spouse, mtw the aurvMmg spouss's name and address here

~ decessed and the sunriving spouse t~vingtoget+~er
at the same a d d m when t b d e c m d dl&?

(a) Were

I

yes
NO
[If 'Yes,' no on to h m 17.) (It "No." answer ml.1
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tb) If elt)rsr the deceased or surviving spouse waa sway from home (whMhsr or not tmporerlly) when the deceased
d i d , give ths following:
Who was away?
D m I m home

w

1~etwwrnabem began

~eceased

a

~urvlvlngspouse

Ikason they wem a m at t h of death

Hyou~~#mrhrhgrpouae,andHyou~under~~,~wer17.

{a] Are ~ O U
so dlsaMed that you cannot work or wm there some
period during the last 14 months Men y w were so disabled
that vou couid not work?
+

17*

-

my-

'Month, day, yearl

Ib) If "Yes," enter the date you became diabled.
W w e r 18 ONLY if you are the #ruiving spouse.
Were you marrled before your marriage to the deceased?
( ~ "yes,
f
g~ the fol~owingabout each of your previous
m r n m a g I~f ,yw need more spae, use "Ramarks* section on
back page or attech a s-rete
shrret.1
T o w h w n m d (Nameat-I

When (Month, day,

I

I

How marriage endad

your
pr-lo-

Maam

Mnrriege wrformed by:
-C
or p u ~ l co ~ d a l
Wler t w n tn

OY~S

D

o

I

Where (&far name of City end State)

WI

I

When CMonth, day, YBM/

Whew IEhtcrr name of Citv end Ststd

Spew's dute of blrth (orage)

If r p o w dm,-

m ' r %cld h u r i t y N u m b (If r

gha date of death

,,,/,I

~ nw
e unknown, SO Indicat8j

,
,
,

Remds: TYw m y use thls awce for my eXp,anstfofl, I? yw nmd mom spuce, attech a sepmte shwtl

I d u d m llndsr pmdty of d t w that I h w e m k a s d all the informatron on thb form, and on m y
acEompMylng itatarfwmr, mt~it is tnre mi mmct to w best of my I t n o a g e .
S i a ~ t u r eIRm nevllir,

SIGNATURE OF APPLICANT
(Write in inkl

Date /Month, day, yeer)

W I e initial, last

Telephone h r n b r ( 3 at W c h You May Re
Contacted Durlrtg the Day

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(h
cod.)

Malllng Addrtms (#umber and street, Apt. No., P.O. Box, or &rat Route)

CkyandStata

UP

a

l3mr Name of County (It any) in wRich you now Iiw

Whmssus are requbed ONLY If thC application haa been aignd by mark (XI above. If d g d by mark (XI, two
witmmm to the slgnlng who knuw the applicant muet slgn below, givlng their full addnrssw.
1. Q~rwtumof Whmm

2. S ~ n a t u nof W l t w ~

Addma6 (Numbr snd M ,
City, State, and 2lP Code)

Address (Number and 8tre6t. Clty, State, and LIP Cde}

I
Form -4-W

( 6 - r n EF f02-2008)

Psge 3

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RECElPT K I R YOUR C I A M FOR THE SOCIAL BECURI'TY WMPSUM DEATH PAYMENT
DATE CLAIM RECEIVED

SSA OFFICE

TELEPHONE NUMBER TO CALL IF YOU HAVE A QUESTION
OR SOMETHIMQ TO REPORT

TELEPHONE NUMBER

RECEIPT FOR Y W R CLAlM
In the meantime, If you change your mailing address, you
Ywr apflcation for the lumpsum death pawent has
should report the change.
bsen received and wlll be processed as qulekly air
possik.

Always glve us your claim number when writing or
telephoning about your claim.

-

You should hear from us within
days after you
have g h us all the information we requested. Some

If you have any qumtto~sabout your claim, we will be glad
to hdp you.

claims may take longer if additional informmion is needed.

I

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

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WUH=TTON AND USE O f IWORMATION FROM YOUR APWCATIOM PRIVACY AMIPAPERWORK ACT
NOTICE
I.

The Social Sacurlty Admintstratlon is authorized to
collect the Informadon on this form under sectiona
202iiI m d 20Sia) of the Social Securlty Act, as
m n d d (42 U.S.C. 402(i} and 406(e)).

II. Whlk P is voluntary, exce
in the ckcumstances
e lained below, for you to t trnlsh the lnformatlon on
m% tmn t o S O C I ~ I security, m
payment may be pald unless an appllcat on has been
reoehred by a Social Security offlce. Your response is
mandatory where the refusal to dlsclme certain
lnformatlon affectkg your right to payment would
retlm a fraudulent Intent to secure payment not
audwked.by tfie Social Security Act.

Yrn

The informadon on this form ts n d e d t o enable Soclal
Securlty to d a t m l n e if you are entltled to the
lurnprwm death peyment. It will also enable us to
determine If there am any s w i v o r s of the daceesed
who may qualify for monthly Soclal Securfty M e f k
as dependems of the d-ased.

I

IV. M b r e to prwlds all or part of thls informadon could
prevent an eccurate and thnely decislon on your clalrn,
and could mult In the loss of some benew for ellgible
-rn
of the d.V.

Althtgh the lnformatlon you fumlrh on thls form is
almost never used for any o w purpore than stated in
Part Ill, abw, them is a possibility that In the
a d m l n ~ i o nof the Swial SecurZty programs or for
the drnlnkmation of programs rwuiring coordlndon
with thb S d a t Sswrlty Administration, Information
may be d h k e d to a t m h r person or to another
QWemmeRtanmcy 88 f0lows:

1. To enable a third party or an agency to m i s t
Soclal Security in establhhlng rights to Social
Security benefits andlor coverage.
2. To comply with Federal laws requiring the rel-e
of irrFrwmatlon from Social Security records (erg.,to
the Gwernmeni Accountabltity Office and the
Veterans Ad mlniatration).
3. To facilitate statistical research and audit activities
necsasary to assure the integrity and Improvement
of the Social Securlty programs (e.g., to the
k m a u of the Census and private c o m under
contract to Social Security).

VI. The Information you provlde may also be used without
your consent in automated matching programs. Thege
matching programs ar* computer cornparisow of
Social Securiiy Administration records with records
kept by other Federal agencies or State and local
govsmmsnt agencies. Information from these
matchlng programs can be used t o errtsbllsh or verlfy a
person's eligibility far Federally funded w administered
benefit pr r a m and for repayment of payments or
dsllnguanodebts unda these proprams.

T h m and other reasons why information a b u t you
may bo useti w given out are explained In ttw Federal
R ister If you would like more i n f m a t i o n Y E 7
, get in touch with any Social Security office.

a"--

Pawwork IWhcIbn AotSMmmM-Tbisidhwimeollection~
t b e r q ~ , o f 4 4 U . S . C 53507,
.
asamendedbysaction20f
tbtPltpsrrwoakRedWhAdoff995. Y m d o n w U t a ~ ~ ~ W v p e ~ y a v W O f f I o c o f h g e m e m a a d
c m W d e . WedmatethatitdEalreabcart 1 S ~ r n ~ t b e ~ , ~ t b e f a c t s , d ~ ~ t h e g u c s tSENDOR
i o a s .
BBPK; TEiE (30FYlRM 'Nl YOUR LOCAL SOCIAL S E C U W Y OFPICE, To ibd the mearest ob6ce, d
14W772-12l3. M a c o m m e o t s onour timedmatcabovem SSA, 6401 Secarity Blvd., B a l w , MD 212356401.
Fwm 88A-8-F4 (6-20031 EF 102-2000)

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V.S. GOVEWMENT PAIHTLNG OFFICE: 2-*<