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

Social Security Administration

Form Approved
OMB No. 0960-0013

TOE 120/145/155

APPLICATION FOR LUMP-SUM DEATH PAYMENT*
I apply for all insurance benefits for which I am eligible under Title II (Federal OldAge, 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
or Self-Employed Person
(herein referred to as the "deceased")

FIRST NAME, MIDDLE INITIAL, LAST NAME

Male

(b) Check (X) one for the deceased

Female

(c) Enter deceased's Social Security Number
2.

PRINT your name

3.

Enter date of birth of deceased
(Month, day, year)
(a) Enter date of death
(Month, day, year)

4.

FIRST NAME, MIDDLE INITIAL, LAST NAME

(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.

6.

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

No

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)
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.

Yes

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?

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

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

(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) and (c).)

From: (Month, Year)

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?
9.

Did the deceased work in the railroad industry for 7 years
or more?
Form SSA-8 (11-2013) EF (11-2013)
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Destroy Prior Editions

Yes

No

Yes

No

Yes
No
10. (a) Did the deceased ever engage in work that was covered
under the social security system of a country other than the (If "Yes," answer (b).) (If "No," go on to item 11.)
United States?
(b) If "Yes," list the country(ies).
11. (a) Is the deceased survived by a spouse?

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
No
Yes
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:

Spouse's date of birth (or age)

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

Clergyman or public official
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
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)

/

(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
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)

/

/

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?

No
Yes
(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

Form SSA-8 (11-2013) EF (11-2013)

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No

Yes

16. (a) Were the deceased and the surviving spouse living
together at the same address when the deceased died?

(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?
Deceased
Surviving spouse
Date last home
Reason absence began
Reason they were apart at time of death
If separated because of illness, enter
nature of illness or disabling condition.

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
Yes
period during the last 14 months when you were so disabled
that you could not work?
(b) If ''Yes,'' enter the date you became disabled.
(Month, day, year)

18.

Answer 18 ONLY if you are the surviving spouse.
Were you married before your marriage to the deceased?

Yes

No

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:

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)

/

/

For additional information about survivor benefits see our publication at www.socialsecurity.gov.
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.
Date (Month, day, year)

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

Telephone Number(s) at Which You May
Be Contacted During the Day

u

(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)

Form SSA-8 (11-2013) EF (11-2013)

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

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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)
Privacy Act Statement - Application for Lump-Sum Death Payment
Section 202(i) of the Social Security Act, as amended, authorizes us to collect this information. We will use the
information you provide to determine your eligibility for the lump-sum death payment and to determine if we need
additional information.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may
prevent an accurate and timely decision on any claim filed, or could result in the loss of benefits.
We rarely use the information you supply us for any purpose other than to make a determination regarding your
eligibility for lump-sum death payment and to authorize payments to the widow, widower, or children of the deceased
beneficiary. However, we may use it for the administration and integrity of our programs. We may also disclose the
information to another person or to another agency in accordance with approved routine uses, including but not limited
to the following:
1) To enable a third party or agency to assist in establishing rights to Social Security benefits and/or coverage;
2) To comply with Federal laws requiring the release of information from our 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 our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
We also may use the information you give us in computer matching programs. Matching programs compare our
records with records kept by other Federal, State and local government agencies. We use the information from these
programs to establish or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you provided us is available in our Systems of Records Notice
entitled, Claims Folder System, 60-0089. Additional information about this and other system of records notices and
our programs are available online at www.socialsecurity.gov or at 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 (OMB) control number. We estimate that it will take about 10
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 21235-0001.
Form SSA-8 (11-2013) EF (11-2013)

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