SSA-1724

Claim For Amounts Due In Case Of A Deceased Beneficiary

Download and Print the SSA-1724

Social Security Administration
CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED SOCIAL SECURITY RECIPIENT
Form Approved OMB No. 0960-0101
Page 1
PRINT NAME OF DECEASED
SOCIAL SECURITY NUMBER OF DECEASED
If the deceased received benefits on another person's record, print name of that worker
NAME OF THE WORKER
The deceased may have been due a Social Security payment at the time of death. The Social Security Act provides that amounts due a deceased may be paid to the next of kin or the legal representative of the estate under priorities established in the law. To help us decide who should receive any payment due, please COMPLETE THIS ENTIRE FORM and RETURN it to us in the enclosed envelope.
This claim for the amounts due from the Social Security Administration is being made on behalf of the family or the estate of
(name of deceased)
_________________________ who died on ______________ day of ________________ _________________
(month)
(year)
and who lived in the state of _________________________ .
PRINT NAME OF APPLICANT
RELATIONSHIP TO DECEASED (Widow, Son, Legal Representative, etc.)
THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVE OF THE DECEASED NAMED ABOVE:
1.
NAME OF SURVIVING WIDOW(ER) (Please print. If none, state "NONE")
ADDRESS OF SURVIVING WIDOW(ER) (Please print house number, street, apt. number, P.O. Box, rural route, city, state, and ZIP code)
ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER) NAMED ABOVE.
WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE SAME HOUSEHOLD WITH THE DECEASED AT THE TIME OF DEATH?
YES
If "YES", then SKIP items 2,3,4,5 and SIGN at bottom of page 2.
NO
WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT ON THE SAME EARNINGS RECORD AS THE DECEASED AT THE TIME OF DEATH?
YES
If "YES", then SKIP items 2,3,4,5 and SIGN at bottom of page 2.
NO
(Go on to item 2)
2.
ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND STEPCHILDREN; INCLUDE GRANDCHILDREN AND STEP-GRANDCHILDREN IF THEIR PARENTS ARE DISABLED OR DECEASED; OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF THE DECEASED. IF NONE OF THE ABOVE, SHOW "NONE" AND GO ON TO ITEM 4.
NUMBER
PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD Remarks -(If you need more space for explaining any answers to the questions, attach a separate sheet.)
NAME OF CHILD
ADDRESS OF CHILD (Include house number, street, apt. number, P.O. Box, rural route, city, state, and ZIP code)
RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)
SOCIAL SECURITY NUMBER OF CHILD
NAME OF CHILD
ADDRESS OF CHILD (Include house number, street, apt. number, P.O. Box, rural route, city, state, and ZIP code)
RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)
SOCIAL SECURITY NUMBER OF CHILD
And much more...