SSA-723

Statement Regarding The Inferred Death Of An individual By Reason Of Continued And Unexplained Absense

Download and Print the SSA-723

All items on this form must be answered or marked "unknown" If you need more space for answers, attach a separate sheet.

Paperwork Act Notice:
Your response to this request is voluntary. The Social Security Administration will use the information you furnish to make a finding about the inferred death of the missing person. The information is needed by the Social Security Administration to help process a claim for Social Security Benefits. Authority to collect this information is contained in 20 CFR 404.720 and 404.721.
NAME OF MISSING PERSON
SOCIAL SECURITY NUMBER
/
/
I UNDERSTAND THAT THIS STATEMENT IS TO BE CONSIDERED IN CONNECTION WITH AN APPLICATION FILED BY THE APPLICANT SHOWN BELOW FOR BENEFITS PAYABLE UNDER THE SOCIAL SECURITY ACT AND THAT THE APPLICANT'S RIGHT TO SUCH BENEFITS IS SUBJECT TO A DETERMINATION AS TO THE INFERRED DEATH OF THE MISSING PERSON, ALSO LISTED BELOW.
FULL NAME OF APPLICANT

1. My relationship to the applicant is CHILD, MOTHER, CLOSE FRIEND, CASUAL FRIEND, ETC.

2. Give the name and address of the person with whom the missing person was living at the time of disappearance. - NAME ADDRESS

3. My relationship to the missing person is
CHILD, MOTHER, CLOSE FRIEND, CASUAL FRIEND, ETC.

4. I have known the missing person since SPECIFY DATE

5. a. When was missing person born? - MONTH-DAY-YEAR
b. Where was missing person born? CITY OR TOWN - COUNTY - STATE OR FOREIGN COUNTRY

6. If any of the missing person's children, brothers, sisters, or parents are living now, give the following information. If none, or unknown, so indicate. - NAME - RELATIONSHIP - ADDRESS

And much more...