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Get SSA-1724-F4 2016-2024

NAME OF CHILD ADDRESS OF CHILD Include house number street apt. number P. O. Box rural route city state and ZIP code Form SSA-1724-F4 01-2010 EF 10-2012 Use Prior Editions Page 1 If any child listed in item 2 has a different name from that given at birth attach a separate sheet with the following information Child s Present Name Name Given At Birth and a brief explanation for the difference e.g. Marriage or Court Order. Form Approved OMB No* 0960-0101 Social Security Administration CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED SOCIAL SECURITY RECIPIENT PRINT NAME OF DECEASED SOCIAL SECURITY NUMBER OF DECEASED NAME OF THE WORKER If the deceased received benefits on another person s record print name of that worker The deceased may have been due a Social Security payment at the time of death. The Social Security Act provides that amounts due a deceased 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 ENTIRE FORM and RETURN it to us in the enclosed envelope. This claim for the amounts due from the Social Security Administration is being made on behalf of the family or the estate of who died on day of name of deceased month year and who lived in the state of. RELATIONSHIP TO DECEASED Widow Son Legal Representative etc* PRINT NAME OF APPLICANT THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVE OF THE DECEASED NAMED ABOVE NAME OF SURVIVING WIDOW ER Please print* If none state NONE ADDRESS OF SURVIVING WIDOW ER Please print house number street apt. number P. O. Box rural route city state and ZIP code ENTER SOCIAL SECURITY NUMBER S OF WIDOW ER NAMED ABOVE* WAS THE WIDOW ER NAMED ABOVE LIVING IN THE SAME HOUSEHOLD WITH THE DECEASED AT THE TIME OF DEATH If YES then SKIP items 2 3 4 5 and SIGN at bottom of page 2. WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT ON THE SAME EARNINGS RECORD AS THE DECEASED AT THE TIME OF DEATH YES NO Go on to item 2 ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND STEPCHILDREN INCLUDE GRANDCHILDREN AND STEP-GRANDCHILDREN IF THEIR PARENTS ARE DISABLED OR DECEASED OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF THE DECEASED. IF NONE OF THE ABOVE SHOW NONE AND GO ON TO ITEM 4. NUMBER PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD Remarks - If you need more space for explaining any answers to the questions attach a separate sheet. Include adopting parents and stepparents. If none show None IF THERE ARE NO LIVING PARENTS GO ON TO ITEM 5. NAME OF LIVING PARENT ADDRESS OF LIVING PARENT Include house number street apt. number P. O. Box rural route city state and ZIP code LEGAL REPRESENTATIVE OF THE DECEASED S ESTATE Skip this item if relatives are listed in 1 2 or 4. 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.

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