Form SSA-7-F6 - Revised SSA-7-F6 - Revised Application for Parent's Insurance Benefits

Social Security Administration

0TEL

Form Approvec
OMB No 0960-001;
(Do not write in this space)

TOE 120/145/155

APPLICATION FOR PARENT'S INSURANCE BENEFITS*
I apply for all insurance benefits for which I am 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.
*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.) For additional information about this
application a factsheet to Form SSA-7 is available at www.socialsecurity.gov
FIRST NAME, MIDDLE INITIAL, LAST NAME

1. (a) PRINT name of deceased wage earner or selfemployed person (herein referred to as the
"Deceased.")

(b)
(c)

2. (a )
(b)

( c)

3. (a)
(b)

Female

Male

Check (X) one for the Deceased.

--- I -- I ----

Enter Deceased's Social Security number.

FIRST NAME, MIDDLE INITIAL, LASi NAME

PRINT your name.

--- I -- I----

Enter your Social Security number.
Enter your name at birth if different from item 2
(a).
Were you receiving at least one-half of your support f rom the
Deceased at the time the Deceased became disabled under the
Social Security law or at the time of death?
Have you filed proof of this support with the Social Security
Administration?

No

Yes

(If "No," go on
to item 4.)

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

No

Yes

PART I - INFORMATION ABOUT THE DECEASED
MONTH, DAY, YEAR

4. Enter date of birth of Deceased.
5.

(a )
(b)

6. (a)

(b)

( c)

Enter date of death.

"

MONTH, DAY, YEAR
CITY AND STATE

Enter place of death.

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?
Enter name of person on whose Social Security
record other application was filed.

-

No

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

Unknown

(If "No" or "Unknown" go
on to item 7.)

FIRST NAME, MIDDLE INITIAL, LAST NAME

Enter Social Security number of person named in (b), (If
"Unknown," so indicate.)

--- I

-- I----

Answer Item 7 ONLY if the Deceased Died Prior to Full Retirement Age or Prior to One Year Past Full Retirement Age, and
Within the Past 4 Months.

7.

(a)
(b)

Was the Deceased unable to work because of a disabling condition at
the time of death?

No

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

MONTH, DAY, YEAR

Enter date disability began.

Form SSA-7-F6 (06-2016) UF (06-2016) Destroy Prior Editions

Yes

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

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(Over)

8. (a)

(b)

(c)

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

No

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

(If nNo," go on
to item 9. )

From: (Month, year)

To: (Month, year)

Enter dates of service.
Have you received, or do you expect to receive, a benefit from any
other Federal agency?

Yes

�

No

Answer Item 9 ONLY If Death Occurred Within the Last 2 Years.
9. (a) About how much did the Deceased earn from employment and

�

self-employment during the year of death?

(b)

10. (a)

About how much did the Deceased earn the year before death?

AMOUNT$

Unknown

AMOUNT$

Unknown

____.

(b)

No

Yes

Did the deceased have wages or self-employment income covered
under Social Security in all years from 1978 through last year?

(If "Yes," skip to
item 11.)

(If nNo," answer
(b).)

List the years from 1978 through last year in which the deceased did not
have wages or self-employment income covered under Social Security.

11. Check if applicable:

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.

PART II - INFORMATION ABOUT YOURSELF
12. (a) Enter your date of birth.
(b)

�

MONTH, DAY, YEAR

�

Enter name of State or Foreign country where you were born.

If you have already presented, or if you are now presenting, a public or religious record of your birth
established before you were age 5, go on to item 13.
(c)

Was a public record of your birth made before you were age 5?

(d)

Was a religious record of your birth made before you were age 5?

--+

Yes

No

Unknown

__.

Yes

No

Unknown

Yes

No

13. (a) Have you married since the death of the Deceased?
(b)

Enter below the information requested about the marriage.

To whom married

When (Month, day, year)

Where (Name of City and State)

How marriage ended (If still in effect, write "Not Ended")

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

D Clergyman or public official
D Other (Explain in "Remarks")

Spouse's date of birth (or age)

Spouse's Social Security Number (If "None" or "Unknown," so indicate)

14.

Have you ever filed an application for Social Security benefits, a
(a)
period of disability under Social Security, Supplemental Security
Income, or hospital or medical insurance under Medicare?

Form SSA-7-F6 (06-2016) UF (06-2016)

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If spouse deceased, give date of death

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

-- I ---No

(If "No, n go on
to item 15.)

(b)
(c)

Enter name of person on whose Social Security record you filed
other application.
Enter Social Security number of person named in (b). (If
"Unknown," so indicate.)

.

--- I -- I

----

15.

Were you in the active military or naval seivice (including Reserve or
National Guard active duty or active duty for training) after September 7,
1939 and before 1968?

Yes

No

16.

Did you, your spouse, or the Deceased work in the railroad industry for 5
years or more?

Yes

No

17.

(a) Do you have social security credits (for example, based on work or
residence) under another country's social security system?
------+
(b)

Yes

No

(If "No," go on
to item 18.)

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

List the country(ies).

Answer Item 18 ONLY if the Deceased Died Before This Year.
18.

(a) How much were your total earnings last year?
(b)

$

Place an "X" in each block for EACH MONTH of last year in which you did not earn
in wages, and did not perform substantial services in
more than*$
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".

NONE

II

*Enter the appropriate monthly limit after reading the instructions, "How Your Earnings Affect
Your Benefits".

19.

(a) How much do you expect your total earnings to be this year?
(b)

Place an "X" in each block for EACH MONTH of this year in which you did not earn or
in wages, and did not or will not perform
will not earn more than*$
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".

�

ALL

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

$
NONE

.

I

I

ALL

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

Answer This Item ONLY 1f You Are Not m the Last 4 Months of Your Taxable Year (Sept., Oct., Nov., and Dec., if
Your Taxable Year is a Calendar Year).
20. (a) How much do you expect to earn next year?
.
$
(b)

21.

NONE

I

ALL

Place an "X" in each block for EACH MONTH of next year in which you do not expect
in wages, and do not expect to perform substantial
to earn more than*$
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".

JAN

FEB

MAR

APR

MAY

JUN

*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".

JUL

AUG

SEPT

OCT

NOV

DEC

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

MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you could
automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age
65. If you are not eligible for automatic enrollment in Medicare Part B, you will need to contact Social Security to request
enrollment.
Form SSA-7-F6 (06-2016) UF (06-2016)

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(Turn to Page 4)

Complete Item 22 ONLY If You Are Within 3 Months of Age 65 or Older
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that
Medicare Part A doesn't cover, such as some of the services provided by physical and occupational therapists and some home
health care. If you enroll in Medicare Part B, you will tiave to pay a monthly premium. The amount of your premium will be
determined when your coverage begins. In some cases, your premium may be higher based on information about your income
we receive from the Internal Revenue Service. Your premiums will be cfeductea from any monthly Social Security, Railroad
Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a
letter explaining how to pay your premiums. You wilf also get a letter if there is any change in the amount of your premium.
Late Enrollment Penalty paragraph (insert here)

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medica[E:Lprescription drug plans and
when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). A Medicare
Representative can also tell you about agencies in your area that can help you choose your prescription drug coverage.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the montnly premiums, annual deductibles, and prescription
co­payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit
the nearest Social Security office.
22. Do you want to enroll in Medicare Part B (Medical Insurance)?

Yes

No

Select "No" if you are already enrolled under your own Social Security Number.
REMARKS (You may use this space for any explanations. If you need more space, attach a separate

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 or misleading statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other
penalties, or both.

SIGNATURE OF APPLICANT

Telephone number(s) at which you may
be contacted during the day

Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN

HERE

.....

FOR
OFFICIAL
USE ONLY

Routing Transit Number

Date (Month, day, year)

---

(AREA CODE)
Direct Deposit Payment Address (Financial Institution)
C/S Depositor Account Number
No Account

D
D Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)
City and State

ZIP 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 who know
the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature block.
2. Signature of Witness
1. Signature of Witness
Address (Number and Street, City, State and ZIP Code)

Fonn SSA-7-F6 (06-2016) UF (06-2016)

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

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Collection and Use of Information From Your Application
- Privacy Act Notice/Paperwork Reduction Act Notice

See Revised Privacy
Act Statement Attached

Section 202(h) of the Social Security Act, as amended, authorizes us to collect this information. We will use this
information to help us determine your entitlement to benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent
us from making an accurate and timely decision on your claim, and could result in the denial or loss of benefits.
We rarely use the information you supply for any purpose other than for determining eligibility for benefits. However, we
may use the information for the administration of our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with
•
us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records 60-0089, entitled Claims Folder System. Additional information about this system of records notice
and our programs is available from our Internet website at www.socialsecurity.gov or at your local Social Security office.
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.
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. The OMB control number for this collection is
0960-0012. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions.
Send onlv comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.

Form SSA-7-F6 (06-2016) UF (06-2016)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 205, 223, 226, and 806 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent us from making an accurate and timely decision on your
entitlement to Social Security benefit payments.
We will use the information to determine your eligibility for Social Security benefits. We may
also share your information for the following purposes, called routine uses:


To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act). Such disclosures include, but are not limited to, release of information to:
Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance
Act and for administering provisions of the Social Security Act relating to railroad
employment; and Department of Veterans Affairs for administering 38 U.S.C. 1312, and
upon request, for determining eligibility for, or amount of, veterans benefits or verifying
other information with respect thereto pursuant to 38 U.S.C. 5106; and



To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under the routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0059, Earnings Recording and Self-Employment Income System, as published in the
Federal Register (FR) on January 11, 2006, at 71 FR 1819; 60-0089, entitled Claims Folders
Systems, as published in the FR on April 1, 2003, at 68 FR 15784; 60-0090, entitled Master
Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and 60-0321,
entitled Medicare Database, as published in the FR on July 25, 2006, at 71 FR 42159.
Additional information and a full listing of all our SORNs are available on our website at
www.ssa.gov/privacy.

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY PARENT'S INSURANCE BENEFITS
SSA OFFICE
DATE CLAIM RECEIVED
BEFORE YOU RECEIVE
A NOTICE OF AWARD
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR
SOMETHING TO
REPORT

(AREA CODE)
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.

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.

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.

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

In the meantime, if you have a change of address, or if there is

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

SOCIAL SECURITY CLAIM NUMBER

CLAIMANT

DECEASED'S NAME (If surname differs from name of claimant)
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
• Change of Marital Status - Marriage, divorce, annulment of
I!-- You change your mailing address for checks or residence.
marriage. You must report marriage even if you believe
(To avoid delay in receipt of checks you should ALSO file a
that an exception applies.
regular change of address notice with your post office.)
• Custody Change - Report if a person for whom you are
filing, or who is in your care dies, leaves your care or
custody, or changes address.

• 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 D (are) D (are not) earning wages of more than
a month.
$

o

o

You
(are)
(are not) self-employed rendering
substantial services in a trade or business.

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 required by law and adjust benefits under the
earnings test. 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.

(Report AT ONCE if this work pattern changes.)
• 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 court
order in connection with a crime.

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:
• 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.

• You have an unsatisfied felony or arrest warrant for
more than 30 continuous days for flight to avoid prosecution
or confinement, escape from custody or flight escape.
• You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.
Form SSA-7-F6 (06-2016) UF (06-2016)

For general information about Social Security, visit our web site at
www.socialsecurity.gov.
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