SSA-7

Application For Parents Insurance Benefits

Download and Print the SSA-7

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.
(Do not write in this space)


*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).

3.
(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? - Yes - No
(If "Yes," answer (b).)
(If "No," go on to item 4.)

(b) Have you filed proof of this support with the Social Security Administration? - Yes - No

And much more...