SSA-5

Application For Mother's Or Father's Insurance Benefits

Download and Print the SSA-5

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.

The information you furnish on this application will ordinarily be sufficient for a determination on the lump-sum death payment. For additional information about this application a fact sheet to Form SSA-5 is available at www.socialsecurity.gov
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*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)


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.

3. Enter your name at birth if different from item 2.

4. (a) Enter your date of birth. - MONTH, DAY, YEAR
(b) Enter name of State or foreign country where you were born.

Please read carefully before answering item 5
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, such 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.

And much more...