Form SSA-8 Application For Lump-Sum Death Payment

Form SSA-8 (XX-20XX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0013

APPLICATION FOR LUMP-SUM DEATH PAYMENT*
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) of the Social Security Act, as presently amended,
on the named deceased's Social Security record.
(This application must be filed within 2 years after the date of death of the wage earner
or self-employed person.)
* This may serve as an application for insurance benefits payable under the
Railroad Retirement Act.
1.

PRINT your name

2.

(a) PRINT name of Deceased Wage Earner FIRST NAME, MIDDLE INITIAL, LAST NAME
or Self-Employed Person (herein
referred to as the "deceased")

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter deceased's Social Security Number
3.

Enter date of birth of deceased
(Month, day, year)

4.

(a) Enter date of death
(Month, day, year)
(b) Enter place of death
(City and State)

ANSWER ITEM 5 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.
5.

(a) About how much did the deceased earn from employment AMOUNT
and self-employment during the year of death?
$
(b) About how much did the deceased earn the year
before death?

AMOUNT
$

ANSWER ITEM 6 ONLY IF THE DECEASED DIED PRIOR TO AGE 66 AND WITHIN THE PAST 4 MONTHS
6.

(a) Was the deceased unable to work because of
illness, injuries or conditions at the time of death?

Yes
(If "Yes," answer
(b).)

No
(If "No," go on to item 7.)

(b) Enter the date the deceased became unable to work
(Month, day, year)
7.

(a) Was the deceased in the active military or naval
service (including Reserve or National Guard active
duty or active duty for training) after September 7,
1939 and before 1968?
(b) Enter dates of service.

8.

Yes
(If "Yes," answer
(b) and (c).)
From: (Month, Year)

No
(If "No," go on to item 8.)
To: (Month, Year)

(c) Has anyone (including the deceased) received, or
does anyone expect to receive, a benefit from any
other Federal agency?

Yes

No

Did the deceased work in the railroad industry for
7 years or more?

Yes

No

Form SSA-8 (XX-20XX) UF
9.
(a) Did the deceased ever engage in work that was covered under the
social security system of a country other than the United States?

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(If "Yes," answer (b).)
Yes
No (If "No," go on to item 10.)

(b) If "Yes," list the country(ies).
10. (a) Is the deceased survived by a spouse? If "Yes," enter information about the marriage at the
time of death below. If "No," go on to item 10(b) if the deceased had prior marriages or item
Yes
No
11 if the deceased never married.
Spouse's Name (including Maiden Name) When (Month, day, year)
Where (Name of City and State)
How marriage ended

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:
Social Security Number (If
Spouse's date of birth (or age) Spouse's
none or unknown, please indicate)
Clergyman or public official
Other (Explain in "Remarks")
(b) If the deceased had a prior marriage(s) that lasted at least 10 years, enter the information below. If the
deceased married the same individual multiple times and the remarriage took place within the year
immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more,
include the marriage. If no prior marriages or if information is unavailable, please indicate below.
Spouse's Name (including Maiden Name) When (Month, day, year)
Where (Name of City and State)
How marriage ended
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")

When (Month, day, year)

Where (Name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date
of death

please
indicate
Spouse's Social Security Number (If none or unknown, so
indicate)
(c) If the deceased has a surviving child(ren) as defined in item 11 and the deceased was married to the child's
mother or father but the marriage ended in divorce, enter information on the marriage if not already listed in
10(b). If no prior marriages or if information is unavailable, please indicate below.
Spouse's Name (including Maiden Name) When (Month, day, year)
Where (Name of City and State)
How marriage ended
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")

When (Month, day, year)

Where (Name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date
of death

indicate
Spouse's Social Security Number (If none or unknown, please
so indicate)
11.

The deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent
grandchildren (including stepgrandchildren) may be eligible for benefits based on the earnings record of the deceased.
List below ALL such children who are now or were in the past 12 months unmarried AND:
• Under Age 18
• Age 18 to 19 and attending elementary or secondary school (grade 12 or below) full-time, OR
• Age 18 or older with a disability that began before age 22
(If none, write ''None.'')
Full Name of Child

12.
13.

Full Name of Child

Is there a surviving parent (or parents) of the deceased who
Yes
No
was receiving support from the deceased either at the time
the deceased became disabled under the Social Security law (If "Yes," enter the name and
address of the parent(s) in "Remarks".)
or at the time of death?
Have you filed for any Social Security benefits on the
Yes
No
deceased's earnings record before?
NOTE: If there is a surviving spouse, continue with item 14. If not, skip items 14 through 17.

14. If you are not the surviving spouse, enter the surviving spouse's name and address here

Form SSA-8 (XX-20XX) UF
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15. (a) Were the deceased and the surviving spouse living
Yes
No
together at the same address when the deceased died?
(If "Yes," go on to item 16.) (If "No," answer (b).)
(b) If either the deceased or surviving spouse was away from home (whether or not temporarily) when the
deceased died, give the following:
Who was away?
Deceased
Surviving spouse
Date last home
Reason absence began
Reason they were apart at time of death
If separated because of illness, enter
nature of illness or disabling condition.
If you are the surviving spouse, and if you are under age 66, answer item 16.
16. (a) Are you currently disabled and unable to work or was there a period during the last 14
months when you were disabled and unable to work?

Yes

No

(Month, day, year)

(b) If ''Yes,'' enter the date you became disabled.

Answer item 17 ONLY if you are the surviving spouse.
17. Were you married before your marriage to the deceased? If yes, enter information about your
Yes
No
prior marriage(s) that lasted at least 10 years or ended due to death of the spouse. If you
divorced then remarried the same individual within the year immediately following the year of
the divorce and the combined period of marriage totaled at least 10 years, include the marriage.
If you need more space, use "Remarks" section on back page or attach a separate sheet.
Where (Name of City and State)
Spouse's Name (including Maiden Name) When (Month, day, year)
How marriage ended
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")

When (Month, day, year)

Where (Name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date
of death

Spouse's Social Security Number (If none or unknown, so indicate)
For additional information about survivor benefits see our publication (05-10084) at www.ssa.gov.
Remarks: (You may use this space for any explanation. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge.
Date (Month, day, year)
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
Telephone Number(s) at Which You
May Be Contacted During the Day

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)
City and State

(Area Code)

ZIP Code Enter Name of County (if any) in which you now live

Direct Deposit Payment Information (Financial Institution)
Routing Transit Number
Account Number

Checking

Enroll in Direct Express

Savings

Direct Deposit Refused

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
2. Signature of Witness
1. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)

Address (Number and Street, City, State, and ZIP Code)

Form SSA-8 (XX-20XX) UF
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RECEIPT FOR YOUR CLAIM FOR THE SOCIAL SECURITY LUMP-SUM DEATH PAYMENT
TELEPHONE NUMBER TO CALL IF YOU HAVE A
QUESTION OR SOMETHING TO REPORT

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER
RECEIPT FOR YOUR CLAIM
Your application for the lump-sum death payment has
been received and will be processed as quickly as
possible.

In the meantime, if you change your mailing address, you
should report the change.

Always give us your claim number when writing or
You should hear from us within
days after you
telephoning about your claim.
have given us all the information we requested. Some
claims may take longer if additional information is needed. If you have any questions about your claim, we will be
glad to help you.
CLAIMANT

BENEFICIARY NOTICE CONTROL (BNC) NUMBER

DECEASED'S NAME (If surname differs from claimant's name)

See revised Privacy Act & Privacy Act Statement - Application for Lump-Sum Death Payment
PRA Statements attached
Collection and Use of Personal Information
Section 202 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information
is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and
timely determination on any claim filed and could result in a loss of a Social Security Administration (SSA) provided
benefit.
We will use the information to authorize our one-time disbursement of the lump-sum death payment to a widow,
widower, or children as defined in Section 202. We may also share your information for the following purposes, called
routine uses:
• Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose of
assisting the SSA in the efficient administration of its programs. We contemplate disclosing information under this
routine use only in situations in which SSA may enter a contractual or similar agreement with a third party to
assist in accomplishing an agency function relating to this system of records; and
• To a congressional office in response to an inquiry from that office made at the request of the subject of a record.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in which our
records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and
for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled
Claims Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional
information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
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 10 minutes to
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also 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 regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this burden to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate or
other aspects of this collection to this address, not the completed form