SSA-4

APPLICATION FOR CHILD'S INSURANCE BENEFITS

Download and Print the SSA-4

I apply on behalf of the child or children

listed in item 3 below for all insurance benefits for which they may be eligible under Title II (Federal Old-Age, Survivors and Disability Insurance) of the Social Security Act, as presently amended. (If you are applying on your own behalf, answer the questions on this form with respect to yourself.)

If you are applying for benefits based on the earnings record of a Deceased Worker, 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).

(Do not write in this space)



LIFE CLAIM - DEATH CLAIM

1  (a) PRINT name of Wage Earner or Self-Employed person (herein referred to as the ''Worker'').
FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) PRINT Worker's Social Security number.

2. (a) PRINT your name (unless you are the Worker).
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) PRINT your Social Security number.


And much more...