Application for Lump-Sum Death Payment--MCS with Electronic Signature (Signature Proxy)

MCS TRANSFER TO: RSDHI CLAIMS APPLICATION APPL

NH NAME:

SSN: SEX: BIRTHDATE:

PROOF (A/B/C/F/Q): PROOF TYPE (P/H/N/O):

SELECT CLAIM TYPE(S): 1. RETIREMENT 4. AUXILIARY 7. AGE 72

2. DISABILITY 5. UNINS MED ONLY 8. ESRD

ABBREVIATED APPLICATION: 3. SURVIVOR 6. LUMP SUM

CLAIMANT (IF DIFFERENT)

NAME:

SSN: SEX BIRTHDATE:

PROOF (A/B/C/F/Q): PROOF TYPE (P/H/N/O):

RELATIONSHIP TO NH: 1. SPOUSE (SUBSEQUENT CLAIM: ) 1. RIB

2. SPOUSE WITH CHILD IN CARE 2. DIB

3. CHILD

APPLICANT (IF DIFFERENT) 4. DEPENDENT PARENT

NAME:

SSN: EIN: WILL APPLICANT BE ENTERED IN RPS (Y/N):

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