Form Ssa-1724 - Claim For Amounts Due In The Case Of Deceased Beneficiary printable pdf download

Form Approved

SOCIAL SECURITY ADMINISTRATION

TOE 210

OMB NO. 0960-0101

PRINT NAME OF DECEASED BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER OF

DECEASED BENEFICIARY

If above-named beneficiary received benefits on another

NAME OF INSURED

person's record, print name of the insured person

The deceased beneficiary may have been due a Social Security payment at the time of death. The Social Security

Act provides that amounts due a deceased beneficiary may be paid to the next of kin or the legal representative of

the estate under priorities established in the law. To help us decide who should receive any payment due, please

COMPLETE this form and RETURN it to us in the enclosed envelope.

PRINT ADDRESS OF CLAIMANT

PRINT NAME OF CLAIMANT

(Include house number, street,

apt. number, P.O. Box, rural route, city state and Zip code.)

CLAIM FOR AMOUNTS DUE IN THE CASE OF DECEASED BENEFICIARY

PRIVACY ACT STATEMENT

The Social Security Administration (SSA) is authorized to collect the

administration of programs requiring coordination with SSA, information may

information on this form under Sections 204(d) of the Social Security Act, as

be disclosed to another governmental agency as follows: (1) to assist SSA in

amended (42. U.S.C 404(d)) and section 413(b) of the Federal Mine Safety

deciding who should receive any payments due the deceased beneficiary; (2)

and Health Act of 1977 (30 U.S.C. 923). While it is voluntary for you to

to comply with Federal laws requiring the release of information from Social

furnish the information on this form to SSA, failure to provide the information

Security records (e.g., to the General Accounting Office and the Veterans

may result in nonpayment of the unpaid benefits. The information on this

Administration); and (3) to facilitate statistical research and audit activities

form is needed to determine if any individual meets the specified qualifications

necessary to assure the integrity and improvement of the Social Security

to obtain benefits in the case of a deceased beneficiary as well as the priority

programs (e.g., to the Bureau of the Census and private concerns under

order for payment.

Although the information you furnish on this form is

contract of Social Security).

almost never used for any other purpose than stated in the foregoing, there is

a possibility that for the administration of the Social Security program or for

I am claiming amounts due from the Social Security Administration as the

(Indicate your relationship to the deceased

(i.e. widow, son, etc. or legal representative)

who died on the

day of

, and whose

(Name of decedent)

(Month)

(Year)

fixed permanent home was in the state of

THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVES OF THE DECEASED PERSON NAMED ABOVE:

ADDRESS OF SURVIVING WIDOW(ER)

(Please print

NAME OF SURVIVING WIDOW(ER)

(Please print. If none,

house number, street, apt. number, P.O., box, rural route,

state "NONE".)

city, state and ZIP code)

ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER)

NAMED ABOVE.

(If unknown, indicate "UNKNOWN".)

WAS THE WIDOW(ER) NAMED ABOVE, LIVING IN THE

(If "YES", OMIT items 2,

SAME HOUSEHOLD WITH THE DECEASED AT THE

YES

3, 4, and 5 and SIGN at

bottom of page 2.)

TIME OF DEATH?

WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT

(If "YES", OMIT items 2,

ON THE SAME EARNINGS RECORD AS THE DECEASED

YES

3, 4, and 5 and SIGN at

(Go on to item 2.)

bottom of page 2.)

AT THE TIME OF DEATH?

ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND

NUMBER

STEPCHILDREN; INCLUDE GRANDCHILDREN AND STEPGRANDCHILDREN IF THEIR PARENTS ARE

DISABLED OR DECEASED; OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF

THE DECEASED BENEFICIARY. IF NONE OF THE ABOVE, SHOW "NONE" AND GO ON TO ITEM 4.

PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD

ADDRESS OF CHILD

(Include house number, street, apt.

NAME OF CHILD

number, P.O., box, rural route, city, state and ZIP code)

RELATIONSHIP TO DECEASED

(Grandchild,stepchild,etc.)

SOCIAL SECURITY NUMBER(S) OF CHILD

(If unknown,

indicate "UNKNOWN".)

ADDRESS OF CHILD

NAME OF CHILD

(Include house number, street, apt.

number, P.O., box, rural route, city, state and ZIP code)

RELATIONSHIP TO DECEASED

(Grandchild,stepchild,etc.)

SOCIAL SECURITY NUMBER(S) OF CHILD

(If unknown,

indicate "UNKNOWN".)

SSA-1724

Over

Form

(11-1984) EF (05-2006)

Form Ssa-1724 - Claim For Amounts Due In The Case Of Deceased Beneficiary

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