Fill and Sign the Supplement to Claim of Person Outdside the Social Security Form

PRIVACY ACT STATEMENT YES NO(Month) (Year) of who died on the day of , and whose / / SOCIAL SECURITY NUMBER(S) OF CHILD (If unknown, indicate "UNKNOWN".) / / WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT ON THE SAME EARNINGS RECORD AS THE DECEASEDAT THE TIME OF DEATH? fixed permanent home was in the state of . YES NO (If "YES", OMIT items 2, 3, 4, and 5 and SIGN atbottom of page 2.) (Name of decedent) WAS THE WIDOW(ER) NAMED ABOVE, LIVING IN THE SAME HOUSEHOLD WITH THE DECEASED AT THETIME OF DEATH? NAME OF SURVIVING WIDOW(ER) (Please print. If none, state "NONE".) 2 PRINT NAME OF DECEASED BENEFICIARY SOCIAL SECURITY CLAIM NUMBER OF DECEASED BENEFICIARY If above-named beneficiary received benefits on another person's record, print name of the insured person NAME OF INSURED 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 NAME OF CLAIMANT PRINT ADDRESS 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 THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVES OF THE DECEASED PERSON NAMED ABOVE: (Indicate your relationship to the deceased (i.e. widow, son, etc. or legal representative) 1 ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER) NAMED ABOVE. (If unknown, indicate "UNKNOWN".) ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND 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. NUMBER PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD RELATIONSHIP TO DECEASED (Grandchild,stepchild,etc.) SOCIAL SECURITY ADMINISTRATION TOE 210 Form Approved OMB NO. 0960-0101 RELATIONSHIP TO DECEASED (Grandchild,stepchild,etc.) Form SSA-1724 (11-1984) EF (05-2006) Over ADDRESS OF SURVIVING WIDOW(ER) (Please print house number, street, apt. number, P.O., box, rural route, city, state and ZIP code) (Go on to item 2.) administration of programs requiring coordination with SSA, information may be disclosed to another governmental agency as follows: (1) to assist SSA in deciding who should receive any payments due the deceased beneficiary; (2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the General Accounting Office and the Veterans Administration); and (3) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract of Social Security). The Social Security Administration (SSA) is authorized to collect the information on this form under Sections 204(d) of the Social Security Act, as amended (42. U.S.C 404(d)) and section 413(b) of the Federal Mine Safety and Health Act of 1977 (30 U.S.C. 923). While it is voluntary for you to furnish the information on this form to SSA, failure to provide the information may result in nonpayment of the unpaid benefits. The information on this form is needed to determine if any individual meets the specified qualifications to obtain benefits in the case of a deceased beneficiary as well as the priority order for payment. Although the information you furnish on this form is 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 NAME OF CHILD ADDRESS OF CHILD (Include house number, street, apt. number, P.O., box, rural route, city, state and ZIP code) NAME OF CHILD ADDRESS OF CHILD (Include house number, street, apt. number, P.O., box, rural route, city, state and ZIP code) SOCIAL SECURITY NUMBER(S) OF CHILD (If unknown, indicate "UNKNOWN".) / / (If "YES", OMIT items 2, 3, 4, and 5 and SIGN atbottom of page 2.) I am claiming amounts due from the Social Security Administration as the ADDRESS OF LIVING PARENT (Include house number, street, apt. number, P.O. box, rural route, city, state, and ZIP code) ADDRESS OF LIVING PARENT (Include house number, street, apt. number, P.O. box, rural route, city, state, and ZIP code) ENTER SOCIAL SECURITY NUMBER(S) OF PARENT NAMED. (If unknown, indicate "UNKNOWN".) ENTER NUMBER OF LIVING PARENTS OF THE DECEASED (Include adopting parents and stepparents. If none, show "None".) IF THERE ARE NO LIVING PARENTS, GO ON TO ITEM 5. 3 5 IF ANY CHILD LISTED IN ITEM 2 NOW HAS A NAME DIFFERENT FROM THAT GIVEN AT BIRTH, PRINT BELOW THAT CHILD'S NAME, THE NAME GIVEN AT BIRTH, AND A BRIEF EXPLANATION FOR THE DIFFERENCE. CHILD'S NAME AT BIRTH CHILD'S PRESENT NAME EXPLANATION (Marriage, court order, adoption) NUMBER PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT NAME OF LIVING PARENT NAME OF LIVING PARENT NAME OF LEGAL REPRESENTATIVE (Please print) ADDRESS OF LEGAL REPRESENTATIVE (Please print house number, street, apt. number, P.O. box, rural route, city, state, and ZIP code) Note: If you are applying as legal representative, please submit a certified copy of your letters of appointment. LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Omit this item if relatives are listed in 1, 2, or 4) REMARKS: (If you need more space for explaining any answers to the questions, attach a separate sheet.) COMPUTER MATCHING STATEMENT: We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or p rove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Secu rity Offices. If you want to learn more about this, contact any Social Security Office. PAPERWORK REDUCTION ACT: This information collection meets the clearance 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 con trol number. We estimate that it will take you about 10 minutes to read the instructions, gather the necessary facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR 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. SIGNATURE OF APPLICANT SIGNATUR E (First name, middle initial, last name) DATE (Month, day, year) TELEPHONE NUMBER (Include area code) MAILING ADDRESS (House number and street, apt. number, P.O. box, or rural route) CITY STATE NAME OF COUNTY ZIP CODE 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. SIGNATURE OF WITNESS ADDRESS (House number and street, city, state, and ZIP code) SIGNATURE OF WITNESS ADDRESS (House number and street, city, state, and ZIP code) 4 Form SSA-1724 (11-1984) EF (05-2006) / / ENTER SOCIAL SECURITY NUMBER(S) OF PARENT NAMED. (If unknown, indicate "UNKNOWN".) / /