Fillable SSA-5-BK Application for mother's or father's insurance benefits

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SSA-5-BK Application for mother's or father's insurance benefits

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Has an unmarried child or dependent grandchild of the deceased, who is under age 16 or disabled, lived with you any
time from the month of death through the present month? (This includes adopted child, stepchild, and stepgrandchild.)
(If "Yes," enter the information requested below.)
FemaleMale
(Do not write in this space)
TOE 120/145/155
Form Approved
OMB No. 0960-0003
APPLICATION FOR MOTHER'S OR FATHER'S INSURANCE BENEFITS*
With this application, you are applying for all insurance benefits for which you are 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. The information you furnish on this application will ordinarily be sufficient for a
determination on the lump-sum death payment.
*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).
1. (a) PRINT name of deceased wage earner or self-employed
person (herein referred to as the "deceased").
(b) Check (X) one for the deceased.
(c) Enter deceased's Social Security Number.
2. (a) PRINT your name.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter your Social Security Number.
3. Enter your name at birth if different from item 2(a).
4.
(a) Enter your date of birth.
MONTH, DAY, YEAR
(b) Enter name of State or foreign country where
you were born.
You may receive a mother's or a father's benefit for any month in which you have in your care the deceased's child or
dependent grandchild who is entitled to a child's benefit if the child is:
•
under age 16,
•
or disabled or handicapped (age 16 or over and disability began before age 22).
If you are filing as a surviving divorced mother or father, the child must be your son, daughter, or legally adopted child who
is entitled to child's benefits on the deceased's earnings record.
Mother's or father's benefits are not payable if the only child in your care is a child age 16 or over who is not disabled.
PLEASE READ CAREFULLY BEFORE ANSWERING ITEM 5
5.
Name of child
Months and Year child lived with you (If all, write "ALL")
Social Security Administration
TEL
FIRST NAME, MIDDLE INITIAL, LAST NAME
Yes No
Form SSA-5-BK (10-2018) UF
Discontinue Prior Editions
Page 1 of 7
Marriage performed by:
Spouse's Social Security Number (If none or unknown, so indicate)
(a) Have you (or has someone on your behalf) ever filed an
application for
Social Security benefits, a period of disability under Social Security,
Supplemental Security Income, or hospital or medical insurance under
Medicare?
Is there a surviving parent (or parents) of the deceased who was receiving
support from the deceased at the time of death or at the time the deceased
became disabled?
INFORMATION ON YOUR MARRIAGE(S)
(a) Enter information about your marriage to the deceased.
(b) If "Yes," list the country(ies).
10.
(If "Yes," enter the name and address of
the parent(s) in "Remarks" on page 5.)
11.
Spouse's Name (including maiden name)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year) Where (Name of City and State)
Marriage performed by:
Date of death
Clergyman or public official
Other (Explain in "Remarks")
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)
Spouse's Name (including maiden name)
When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Spouse's date of birth (or age)
(If "No," go on to
item 7.)
(If "Yes," answer
(b) and (c).)
(b) Enter name of person(s) on whose Social Security record
you filed other application.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter Social Security Number of person named in (b).
(If unknown, so indicate.)
7. (a) Are you, or during the past 14 months have you been, unable to work
because of illnesses, injuries or conditions?
(If "Yes,"
answer (b).)
(If "No," go on
to item 8.)
MONTH, DAY, YEAR
(b) Enter the date you became unable to work.
8. Did you work in the railroad industry for 5 years or more?
9. (a)
Do you have Social Security credits (for example, based on work or
residence) under another country's Social Security system?
(If "No," go on
to item 10.)
(If "Yes,"
answer (b).)
(b) If you remarried after the marriage shown in 11. (a), enter information about the last marriage.
(If none, write "NONE".)
6.
(c) If you had other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether
before or after you married the deceased), enter the information below. 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
10 years or more, include the marriage. (If none, write "NONE".)
NoYes
NoYes
NoYes
NoYes
NoYes
Spouse's date of birth (or age)
Other (Explain in "Remarks")
Clergyman or public official
Form SSA-5-BK (10-2018) UF Page 2 of 7
You
Marriage performed by:
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
12.
Spouse's Name (including maiden name)
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Marriage performed by:
Spouse's date of birth (or age)
Spouse's Name (including maiden name)
Date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Marriage performed by:
Spouse's date of birth (or age)
USE "REMARKS" SPACE ON PAGE 5 FOR INFORMATION ABOUT ANY OTHER MARRIAGES
Spouse's Social Security Number (If none or unknown, so indicate)
(b) Enter information about any other marriage the deceased may have had that lasted at least 10 years (see item
11. (c) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse
(whether before or after you married the deceased). Do not include the marriage to you.
(If none, write "NONE".)
Spouse's Social Security Number (If none or unknown, so indicate)
INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)
Answer this item ONLY if the deceased had other marriages.
(a) If the deceased married after his or her marriage to you, enter the information on the last marriage.
(If none, write
"NONE".)
Spouse's Social Security Number (If none or unknown, so indicate)
Spouse's Name (including maiden name)
If spouse deceased, give date of death
Where (Name of City and State)
Where (Name of City and State)When (Month, Day, Year)
How Marriage Ended
When (Month, Day, Year)
Spouse's date of birth (or age)
13. (a) Were you and the deceased living together at the same address when the
deceased died?
(If "No,"
answer (b).)
(If "Yes," skip to
item 14.)
Who was away?
Reason absence began
IF YOU ARE APPLYING FOR SURVIVING DIVORCED
SPOUSE'S
BENEFITS, SKIP ITEM 13 AND GO ON TO ITEM 14.
(b)
If either you or the deceased were away from home (whether or not temporarily) when the deceased died,
give the following:
Date last at home
Other (Explain in "Remarks")
Clergyman or public official
Other (Explain in "Remarks")
Clergyman or public official
Other (Explain in "Remarks")
Clergyman or public official
No
Yes
Deceased
Form SSA-5-BK (10-2018) UF Page 3 of 7
(b)
I receive a government pension or annuity.
I applied for and am awaiting a decision on my pension or lump sum.
Check if applicable:
Year
No
Yes
Reason you were apart at time of death
If separated because of illness, enter nature of illness or
disabling condition
ANSWER ITEM 14 ONLY IF THE DECEASED DIED BEFORE THIS YEAR. OTHERWISE, GO ON TO ITEM 15.
14.
(b) Place an "X" in each block for EACH MONTH of last year in which you did not
earn more than *$ in wages, and did not perform substantial services
in 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."
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings
Affect Your Benefits".
NONE
MAR
MAY JUL AUG
SEPT OCT NOV DEC
FEBJAN
ALL
JUN
(a) How much were your total earnings last year?
$
(Turn to Page 5)
(b) Place an "X" in each block for EACH MONTH of this year in which you did not or
will not earn more than *$ in wages, and did not or will not perform
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".
ANSWER ITEM 16 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT., OCT., NOV.,
AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR). OTHERWISE, GO ON TO ITEM 17.
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
16.
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
expect to earn more than *$ in wages, and do not expect to perform
substantial 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".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".
(a) How much do you expect to earn next year?
$
15. (a) How much do you expect your total earnings to be this year? $
(If "Yes," check
the box in item (b)
that applies.)
I received a lump sum in place of a government pension
or annuity.
Month
I have not applied for but I expect to
begin receiving my pension or
annuity: (If the date is not known,
enter "Unknown.")
17.
(a) Have you qualified for, or do you expect to qualify for, a pension or
annuity (or a lump sum in place of a pension or annuity) based on
your own employment and earnings for the Federal Government of
the United States, or one of its States or local subdivisions? (Social
Security benefits are not government pensions).
(If "No," go on, to
item 18.)
18.
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.
APR
NONE
MAR
MAY JUL AUG
SEPT OCT NOV DEC
FEBJAN
ALL
JUN
APR
NONE
MAR
MAY JUL AUG
SEPT OCT NOV DEC
FEBJAN
ALL
JUN
APR
Form SSA-5-BK (10-2018) UF Page 4 of 7
Direct Deposit Refused
Enroll in Direct Express
Savings
Checking
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
Direct Deposit Payment Address (Financial Institution)
Account Number
Date (Month, Day, Year)
Telephone number(s) at which you may be
contacted during the day
AREA CODE
Routing Transit Number
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 statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be subject to a fine or imprisonment.
SIGNATURE OF APPLICANT
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks" on page 5, 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 to the signing who know the applicant must sign below, giving their full addresses. Also, print the
applicant's name in the Signature block.
Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code)
Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN
HERE
1. Signature of Witness 2. Signature of Witness
Form SSA-5-BK (10-2018) UF Page 5 of 7
Privacy Act Statement
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 or a dependent’s entitlement to Social Security benefit payments.
We will use the information to determine your or a dependent’s eligibility for Social Security benefits. We may also share
your information for the following purposes, called routine uses:
1. 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
2. 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, 60-0089, entitled Claims Folders Systems, 60-0090, entitled Master
Beneficiary Record, and 60-0321, entitled Medicare Database. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy/sorn.html
.
Paperwork Reduction Act Statement
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.
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.
In the meantime, if you change your address, or if
there is 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.
Always give us your claim number when writing or calling
about your claim.
If you have any questions about your claim, we will be glad to
help you.
TELEPHONE
NUMBER(S) TO
CALL IF YOU
HAVE A
QUESTION OR
SOMETHING TO
REPORT
SSA OFFICE DATE CLAIM RECEIVED
SOCIAL SECURITY
CLAIM NUMBER
CLAIMAINT
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY MOTHER'S OR FATHER'S INSURANCE BENEFITS
BEFORE YOU RECEIVE
A NOTICE OF AWARD
(AREA CODE)
DECEASED'S SURNAME IF DIFFERENT
FROM CLAIMANT'S
- 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 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. 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 1-800-772-1213 (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-5-BK (10-2018) UF Page 6 of 7
• You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)
• 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 (are) (are not) earning wages of more than
$ a month.
You (are) (are not) self-employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes.)
• Change of Marital Status - Marriage, divorce, annulment
of marriage. You must report a change in marital
status even if you believe that an exception applies.
• Custody Change or Disability Improves - Report if a
person for whom you are filing, or who is in your care
dies, leaves your care or custody, changes address, or if
disabled, the condition improves.
• 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 a
court in connection with a crime.
• 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.
CHANGES TO BE REPORTED AND HOW TO REPORT
• You begin to receive a retirement or disability government
pension or annuity (from the Federal government or any
State or any political subdivision thereof) or your pension
or annuity amount changes.
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. 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.
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:
• Visiting the section “Online Services” at our web site at
www.socialsecurity.gov;
• 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.
For general information about Social Security, visit our web
site at www.socialsecurity.gov.
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST
BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
Form SSA-5-BK (10-2018) UF Page 7 of 7
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SSA-5-BK Application for mother's or father's insurance benefits

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Completed 6 May 2020

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