SSA-721

Statement Of Death By Funeral Director

Download and Print the SSA-721

NAME OF DECEASED
SOCIAL SECURITY NUMBER
-
-
FOR SSA USE ONLY
Please complete the items below, and return the form in the enclosed addressed, postage paid envelope. Your assistance and cooperation are appreciated.

PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the Federal Regulations (20 CFR 404.715 and 404.720). While your response is voluntary, we need your assistance to make an accurate and timely determination concerning the death of the individual named above, and to determine if there are survivors who may be eligible for Social Security benefits.

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 prove 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 Security Offices. If you want to learn more about this, contact any Social Security Office.

Paperwork Reduction Act Statement - This information collection meets the 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 control number. We estimate that it will take about 3.5 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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