IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)
This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the Social
Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the application
requests information in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete
part or all of the SSA-24. However, it is usually to your advantage to provide the information because not
providing it could prevent an accurate and timely decision on your claim or could result in the loss of some
benefits or insurance coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to the
Social Security Administration and used by them to determine whether social security benefits may be
payable to surviving dependent(s) of the veteran. Social Security will then contact you regarding any social
security benefits payable based on information given on this form.
If you should have any question about entitlement to social security benefits or the information you have
provided on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When signed
and dated the form SHOULD BE LEFT ATTACHED to your completed
• VA FORM 21-534, Application for Dependency and Indemnity Compensation,
Death Pension and Accrued Benefits by a Surviving Spouse or Child (Including
Death Compensation if Applicable) or
• VA FORM 21-535, Application for Dependency and Indemnity Compensation by
Parent(s) (Including Accrued Benefits and Death Compensation When
Applicable).
Form SSA-24 (04-2014)
WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS
18B. ADDRESS OF WITNESS (No. and street, city, State and
ZIP Code)
19A. SIGNATURE OF WITNESS
19B. ADDRESS OF WITNESS (No. and street, city, State and
ZIP Code)
ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE22. DATE
20. PROOFS RECEIVED
(NAME)
(NAME)
(NAME)
21. PROOFS REQUESTED FROM CLAIMANT OR OTHER
(Specify)
(NAME)
(NAME)
(NAME)
Page 2
DEATH
MARRIAGE
AGE
OTHER (Specify) OTHER (Specify)
AGE
MARRIAGE
DEATH