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

TOE 120/145/155

Social Security Administration

Form Approved
OMB No. 0960-0013

APPLICATION FOR LUMP-SUM DEATH PAYMENT*
I apply for all insurance benefits for which I am eligible under Title II (Federal
Old-Age, Survivors, and Disability Insurance) of the Social Security Act, as
presently amended, on the named deceased's Social Security record.
(This application must be filed within 2 years after the date of
death of the wage earner or self-employed person.)
* This may also be considered an application for insurance benefits payable
under the Railroad Retirement Act.

1. (a) PRINT name of Deceased Wage Earner

FIRST NAME, MIDDLE INITIAL, LAST NAME

or Self-Employed Person
(herein referred to as the "deceased")

Male

(b) Check (X) one for the deceased

/

(c) Enter deceased's Social Security Number

2.

Female

/

FIRST NAME, MIDDLE INITIAL, LAST NAME
PRINT your name

3. Enter date of birth of deceased
(Month, day, year)

4. (a) Enter date of death

(Month, day, year)
(b) Enter place of death
(City and State)

5. (a) Did the deceased ever file an application for Social Security

benefits, a period of disability under Social Security,
supplemental security income, or hospital or medical
insurance under Medicare?

(b) Enter name(s) of person(s) on whose
Social Security record(s) other
application was filed.

Yes

No

(If "Yes," answer
(b) and (c).)

Unknown

(If "No" or "Unknown,"
go on to item 6.)

FIRST NAME, MIDDLE INITIAL, LAST NAME

(c) Enter Social Security Number(s) of person(s) named in (b).
(If unknown, so indicate)

/

/

6. ANSWER ITEM 6 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.
(a) About how much did the deceased earn from employment
and self-employment during the year of death?
(b) About how much did the deceased earn the year before
death?

7.

AMOUNT
$
AMOUNT
$

ANSWER ITEM 7 ONLY IF THE DECEASED DIED PRIOR TO AGE 66 AND WITHIN THE PAST 4 MONTHS.
(a) Was the deceased unable to work because of illness, injuries
or conditions at the time of death?

(b) Enter the date the deceased became unable to work
(Month, day, year)
8. (a) Was the deceased in the active military or naval service
(including Reserve or National Guard active duty or active
duty for training) after September 7, 1939 and before 1968?

Yes
(If "Yes,"
answer (b).)

Yes
(If "Yes," answer
(b) and (c).)
From: (Month, Year)

No
(If "No," go on
to item 8.)

No
(If "No," go on
to item 9.)
To: (Month, Year)

(b) Enter dates of service.
(c) Has anyone (including the deceased) received, or does
anyone expect to receive, a benefit from any other
Federal agency?
the deceased work in the railroad
9. Did
industry for 7 years or more?
Form SSA-8-F4 (5-2003) EF (12-2007)

Destroy Prior Editions

Yes

No

Yes

No
Page 1

10. (a) Did the deceased ever engage in work that was covered

under the social security system of a country other than the
United States?

Yes
No
(If "Yes," answer (b).) (If "No," go on to item 11.)

(b) If "Yes," list the country(ies).

11. Is the deceased survived by a spouse or ex-spouse? (If "No," go on to item 12. If "Yes,"
give the following information about all marriages of the deceased including marriage in
effect at time of death.) (If you need more space, use "Remarks" section on back page
or attach a separate sheet.)

To whom married (Name at Birth)
How marriage ended See

Last
marriage
of the
deceased

No

Yes

When (Month, day, year)

Where (Enter name of City and State)

Revised
#11
Attached
When
(Month,
day, year)

Where (Enter name of City and State)

Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)

Spouse's date of birth (or age)

If spouse deceased, give date of death

/

Spouse's Social Security Number (If none or unknown, so indicate)
To whom married (Name at Birth)
How marriage ended

/

When (Month, day, year)

Where (Enter name of City and State)

When (Month, day, year)

Where (Enter name of City and State)

Previous
marriage
Spouse's date of birth (or age)
Marriage performed by:
of the
Clergyman or public official
deceased
Other (Explain in Remarks)
If none
write "None." Spouse's Social Security Number (If none or unknown, so indicate)

If spouse deceased, give date of death

/

/

12. The deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent
grandchildren (including stepgrandchildren) may be eligible for benefits based on the earnings record of the
deceased.
List below ALL such children who are now or were in the past 12 months UNMARRIED and:
• UNDER AGE 18 • AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

(If none, write ''None.'')
Full Name of Child

Full Name of Child

13. Is there a surviving parent (or parents) of the deceased who was

receiving support from the deceased either at the time the
deceased became disabled under the Social Security law or at the
time of death?

14. Have you filed for any Social Security benefits on the deceased's
earnings record before?

Yes
No
(If "Yes," enter the name and address of the
parent(s) in "Remarks".)
Yes

No

NOTE: If there is a surviving spouse, continue with item 15. If not, skip items 15 through 18.

15. If you are not the surviving spouse, enter the surviving spouse's name and address here
16. (a) Were the deceased and the surviving spouse living together
at the same address when the deceased died?

Yes

No

(If "Yes," go on to item 17.) (If "No," answer (b).)

(b) If either the deceased or surviving spouse was away from home (whether or not temporarily) when the deceased
died, give the following:
Who was away?
Date last home

Deceased
Reason absence began

Reason they were apart at time of death

If separated because of illness, enter nature
of illness or disabling condition.
Form SSA-8-F4 (5-2003) EF (12-2007)

Surviving spouse

Page 2

If you are the surviving spouse, and If you are under age 66, answer 17.

17.

(a) Are you so disabled that you cannot work or was there some
period during the last 14 months when you were so disabled
that you could not work?

Yes

No

(Month, day, year)

(b) If ''Yes,'' enter the date you became disabled.
Answer 18 ONLY if you are the surviving spouse.
18. Were you married before your marriage to the deceased?
(If ''Yes,'' give the following about each of your previous
marriages. If you need more space, use "Remarks" section on
back page or attach a separate sheet.)
To whom married (Name at Birth)

(Month, day, year)
SeeWhen
Revised
#18 Attached

How marriage ended

Your
previous
marriage

Yes

Marriage performed by:

No

Where (Enter name of City and State)

When (Month, day, year)

Where (Enter name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

/

Spouse's Social Security Number (If none or unknown, so indicate)

/

Remarks: (You may use this space for any explanation. If you need more space, attach a separate sheet.)

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.
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number(s) at Which You May Be
Contacted During the Day
(Area Code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Enter Name of 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.
1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State, and ZIP Code)

Address (Number and street, City, State, and ZIP Code)

Form SSA-8-F4 (5-2003) EF (12-2007)

Page 3

RECEIPT FOR YOUR CLAIM FOR THE SOCIAL SECURITY LUMP-SUM DEATH PAYMENT
TELEPHONE NUMBER TO CALL IF YOU HAVE A QUESTION
OR SOMETHING TO REPORT

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER

RECEIPT FOR YOUR CLAIM
In the meantime, if you change your mailing address, you
should report the change.

Your application for the lump-sum death payment has
been received and will be processed as quickly as
possible.

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

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.

If you have any questions about your claim, we will be glad
to help you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

DECEASED'S NAME (If surname differs from claimant's name)

COLLECTION AND USE OF INFORMATION FROM YOUR APPLICATION - PRIVACY ACT/PAPERWORK ACT
See Revised PrivacyNOTICE
Act Statement Attached
I.

II.

The Social Security Administration is authorized to
collect the information on this form under sections
202(i) and 205(a) of the Social Security Act, as
amended (42 U.S.C. 402(i) and 405(a)).

While it is voluntary, except in the circumstances
explained below, for you to furnish the information on
this form to Social Security, no lump-sum death
payment may be paid unless an application has been
received by a Social Security office. Your response is
mandatory where the refusal to disclose certain
information affecting your right to payment would
reflect a fraudulent intent to secure payment not
authorized by the Social Security Act.

The information on this form is needed to enable Social
III. Security to determine if you are entitled to the
lump-sum death payment. It will also enable us to
determine if there are any survivors of the deceased
who may qualify for monthly Social Security benefits
as dependents of the deceased.
Failure to provide all or part of this information could
IV. prevent an accurate and timely decision on your claim,
and could result in the loss of some benefits for eligible
dependents of the deceased.
Although the information you furnish on this form is
V. almost never used for any other purpose than stated in
Part III, above, there is a possibility that in the
administration of the Social Security programs or for
the administration of programs requiring coordination
with the Social Security Administration, information
may be disclosed to another person or to another
government agency as follows:

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 the
Veterans Administration).
3. To facilitate statistical research and audit activities
necessary to assure the integrity and improvement
of the Social Security programs (e.g., to the
Bureau of the Census and private concerns under
contract to Social Security).
The information you provide may also be used without
VI. your consent in automated matching programs. These
matching programs are computer comparisons of
Social Security Administration records with records
kept by other Federal agencies or State and 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.
These and other reasons why information about you
may be used or given out are explained in the Federal
Register. If you would like more information about
this, get in touch with 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
Revised
Statement
Office of Management and BudgetSee
control
number. PRA
We estimate
that it Attached
will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING 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 time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed
form.
Form SSA-8-F4 (5-2003) EF (12-2007)

Page 4

SSA will insert the revised Questions 11 and 18 upon OMB approval of these revisions:
Question 11:
(a) Is the deceased survived by a spouse?

 Yes

 No

If “Yes”, enter information about the marriage in effect at the time of death below. If “No”, go
on to item 11(b) if the deceased had prior marriages or item 12 if the deceased never married.
Spouse’s name
(including maiden name)

When (Month, day, year)

Where (Name of City and
State)

How marriage ended

When (Month, day, year)

Where (Name of City and
State)

Marriage performed by:
 Clergyman or public
official

Spouse’s date of birth (or age) Spouse’s Social Security
Number (If none or
unknown, so indicate)

 Other (Explain in
“Remarks”)

(b) If the deceased had a prior marriage(s) that lasted at least 10 years, enter the information below.
If the deceased married the same individual multiple times and the remarriage took place 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 or unknown, so indicate.___________________________
Spouse’s name
(including maiden name)

When (Month, day, year)

Where (Name of City and
State)

How marriage ended

When (Month, day, year)

Where (Name of City and
State)

Marriage performed by:
 Clergyman or public
official

Spouse’s date of birth (or age) If spouse deceased, give
date of death.

 Other (Explain in
“Remarks”)
Spouse’s Social Security number (If none or unknown, so indicate)

(c) If the deceased has surviving children as defined in item 12 and he or she was married to the
child’s mother or father but the marriage ended in divorce, enter information on the marriage if
not already listed in 11(b).
If none or unknown, so indicate.________________________
Spouse’s name
(including maiden name)

When (Month, day, year)

Where (Name of City and
State)

How marriage ended

When (Month, day, year)

Where (Name of City and
State)

Marriage performed by:
 Clergyman or public
official

Spouse’s date of birth (or age) If spouse deceased, give
date of death.

 Other (Explain in
“Remarks”)
Spouse’s Social Security number (If none or unknown, so indicate)

If you need more space, use “Remarks” section on back page or attach a separate sheet.

Question 18:
Were you married before your marriage to the deceased?

→  Yes

 No

If yes, enter information about your prior marriage(s) that
lasted at least 10 years or ended due to death of the spouse. 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 at least 10 years, include
the marriage. If you need more space, use “Remarks” section
on back page or attach a separate sheet.
Spouse’s name (including
maiden name)

When (Month, day, year)

Where (Name of City and
State)

How marriage ended

When (Month, day, year)

Where (Name of City and
State)

Marriage performed by:
 Clergyman or public
official

Spouse’s date of birth (or age) If spouse deceased, give date
of death.

 Other (Explain in
“Remarks”)
Spouse’s Social Security number (If none or unknown, so indicate)

For additional information about survivor benefits see our publication at
www.socialsecurity.gov.

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:

Privacy Act Statement
Sections 202 (g), 205(a), 223, and 1631 of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will allow the Social Security
Administration (SSA) to determine your potential eligibility for benefit payments and to help us
to decide if additional information is needed. Your response is voluntary. However, failure to
provide this requested information may prevent an accurate and timely decision on any claim
filed, or could result in loss of benefits.
We rarely use the information provided on this form for any purpose other than for the reasons
stated above. 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 routines 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
Medicare benefits 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 determination 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 of Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our 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.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Systems of Record Notice 60-0089 (Claims Folders Systems, SSA,
Office of General Counsel, Office of Privacy and Disclosure. The Notice information about this
form, and any other information regarding our systems and programs, are available on-line at
www.socialsecurity.gov or visit your local 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 10 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.