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Ssa-7 APPLICATION FOR PARENT'S INSURANCE BENEFITS*

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Form SSA-7-F6 (12-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 6
OMB No. 0960-0012
APPLICATION FOR PARENT'S INSURANCE BENEFITS*
(Do not write in this space)
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
1. (a) PRINT name of deceased wage earner
or self-employed person (herein
referred to as the "Deceased.")
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Check (X) one for the Deceased.
Male Female
(c) Enter Deceased's Social Security number.
2.
(a)
PRINT your name.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter your Social Security number.
(c) Enter your name at birth if different from
item 2(a).
(a) Were you receiving at least one-half of your
support from the Deceased at the time the
Deceased became disabled under the
Social Security law or at the time of death?
3.
NoYes
NoYes
(If "Yes,"
answer (b).)
(If "No," go
on to item 4.)
(b) Have you filed proof of this support with the
Social Security Administration?
PART 1 - INFORMATION ABOUT THE DECEASED
MONTH, DAY, YEAR
Enter date of birth of Deceased.
4.
MONTH, DAY, YEAR(a) Enter date of death.
5.
CITY AND STATE(b) Enter place of death.
(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?
6.
NoYes Unknown
(b) Enter name of person on whose Social
Security record other application was filed.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter Social Security number of person
named in (b), (If "Unknown," so indicate.)
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.
(b) Enter date disability began.
7.
(a) Was the Deceased unable to work because
of a disabling condition at the time of death?
NoYes
MONTH, DAY, YEAR
(If "Yes,"
answer (b)
and (c).)
(If "No" or "Unknown" go on
to item 7.)
(If "Yes,"
answer (b).)
(If "No," go on
to item 8.)
Form SSA-7-F6 (12-2018) UF
Page 2 of 6
(b) Enter dates of service.
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?
From: (Month, year) To: (Month, year)
NoYes
NoYes
(If "Yes,"
answer (b) and (c).)
(If "No," go on to
item 9.)
(c) Have you received, or do you expect to receive, a
benefit from any other Federal agency?
Answer Item 9 ONLY If Death Occurred Within the Last 2 Years.
(a) About how much did the Deceased earn from
employment and self-employment during the year
of death?
9.
AMOUNT $
Unknown
(b) About how much did the Deceased earn the
year before death?
AMOUNT $
Unknown
(If "No," answer
(b).)
No
(If "Yes," skip to
item 11.)
Yes
(a) Did the deceased have wages or self-employment
income covered under Social Security in all years
from 1978 through last year?
10.
(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 2 - INFORMATION ABOUT YOURSELF
12.
MONTH, DAY, YEAR
(a) Enter date of birth.
(b) 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.
13.
(c) Was a public record of your birth made
before you were age 5?
NoYes Unknown
(d) Was a religious record of your birth made
before you were age 5?
NoYes Unknown
(a) Have you married since the death of
the Deceased?
NoYes
To whom married
When (Month, day, year)
Where (Name of City and State)
Where (Name of City and State)When (Month, day, year)How marriage ended (If still in effect, write "Not Ended")
Marriage performed by:
Other (Explain in "Remarks")
Clergyman or public official
If spouse deceased, give date of deathSpouse's date of birth (or age)
Spouse's Social Security Number (If "None" or "Unknown," so indicate)
14.
(a) Have you 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?
NoYes
(If "No," go on to
item 15.)
(If "Yes," answer
(b) and (c).)
(b) Enter below the information requested about the marriage.
Form SSA-7-F6 (12-2018) UF
Page 3 of 6
(b) Enter name of person on whose Social Security
record you filed other application.
(c) Enter Social Security number of person named in
(b). (If "Unknown," so indicate.)
15.
Were you 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?
NoYes
17.
(a) Do you have social security credits (for example,
based on work or residence) under another
country's social security system?
NoYes
(If "No," go on
to item 18.)
(If "Yes,"
answer (b).)
Did you, your spouse, or the Deceased work in the
railroad industry for 5 years or more?
NoYes
16.
(b) List the country(ies).
Answer Item 18 ONLY if the Deceased Died Before This Year.
(a) How much were your total earnings last year?
18.
$
NONE
(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".
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
Dec.
(a) How much do you expect your total earnings to be this year?
19.
$
NONE
(b) Place an "X" in each block for EACH MONTH of last year in which you did not earn 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".
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
Dec.
Answer This Item ONLY if You Are Not in the Last 4 Months of Your Taxable Year (Sept., Oct., Nov., and Dec., if Your
Taxable Year is a Calendar Year).
(a) How much do you expect to earn next year?
20.
$
NONE
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".
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
Dec.
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.
(Turn to Page 4)
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.
21.
MONTH
Form SSA-7-F6 (12-2018) UF
Page 4 of 6
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 have 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 deducted 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 will also get a letter if there is any change in the amount of your premium.
Late Enrollment Penalty
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have
Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but did not
sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to March 31) to enroll in Part B, and
coverage will start July 1 of that year.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription 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 monthly premiums, annual deductibles, and prescription co-
payments. 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.
Complete Item 22 ONLY If You Are Within 3 Months of Age 65 or Older
Do you want to enroll in Medicare Part B (Medical
Insurance)?
Select "No" if you are already enrolled under your own
Social Security Number.
NoYes
22.
REMARKS (You may use this space for any explanations. 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. 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
Date (Month, day, year)
Signature (First Name, Middle Initial, Last Name) (Write in ink)
SIGN
HERE
Telephone number(s) at which you may be
contacted during the day
(AREA CODE)
FOR
OFFICIAL
USE ONLY
Direct Deposit Payment Address (Financial Institution)
Routing Transit Number C/S Depositor Account Number
No Account
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.
1. Signature of Witness 2. Signature of Witness
Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Form SSA-7-F6 (12-2018) UF
Page 5 of 6
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.
- 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 only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Paperwork Reduction Act Statement
Form SSA-7-F6 (12-2018) UF Page 6 of 6
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY PARENT'S INSURANCE BENEFITS
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO REPORT
BEFORE YOU RECEIVE A
NOTICE OF AWARD
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.
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 have a change of 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 telephoning
about your claim.
If you have any questions about your claim, we will be glad to
help you.
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
• 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 a trade or business.
(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.
• 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.
• Change of Marital Status - Marriage, divorce, annulment of
marriage. You must report marriage even if you believe that
an exception applies.
• 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.
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.
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.
For general information about Social Security, visit our web
site at www.socialsecurity.gov
.
SSA OFFICE DATE CLAIM RECEIVED
CLAIMANT SOCIAL SECURITY CLAIM NUMBER
DECEASED'S NAME (If surname differs from name of claimant)
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Ssa-7 APPLICATION FOR PARENT'S INSURANCE BENEFITS*

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Completed 3 November 2019

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