SSA-4-BK (With Marked References to the Revised MCS Screens)

TEL

Social Security Administration

Form Approved
OMB No. 0960-0010

TOE 120/145/155

(Do not write in this space)

APPLICATION FOR CHILD'S INSURANCE BENEFITS
I apply on behalf of the child or children listed in item 3 below for all insurance benefits for which they
may be eligible under Title II (Federal Old-Age, Survivors and Disability Insurance) of the Social
Security Act, as presently amended. (If you are applying on your own behalf, answer the questions on
this form with respect to yourself.)
If you are applying for benefits based on the earnings record of a Deceased Worker, 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).
1.

(a) PRINT name of Wage Earner or Self-Employed person
(herein referred to as the ''Worker'').

DEATH
CLAIM

FIRST NAME, MIDDLE INITIAL, LAST NAME

/

(b) PRINT Worker's Social Security number.
2.

LIFE
CLAIM

/

FIRST NAME, MIDDLE INITIAL, LAST NAME

(a) PRINT your name (unless you are the Worker).

/

(b) PRINT your Social Security number.

/

PART I-INFORMATION ABOUT THE WORKER'S CHILDREN

M

F

Check (X) the
Column That
Shows Child's
Relationship to
Worker

CHILD'S SOCIAL
SECURITY NUMBER

Other

Check (X) if
Child 17 or
Older is:

Adopted

Date of
Birth
(Mo.,
day, yr.)

Stepchild
Dependent
Grandchild

NHID;
IDEN

Check
(X)
Sex of
Child

Legitimate

LIST BELOW ALL SUCH CHILDREN (IN ORDER OF
BIRTH BEGINNING WITH THE OLDEST) who are now, or
who were at the appropriate time (above), UNMARRIED
and:
• UNDER AGE 18
• AGE 18 TO 19 (OR TO AGE 23 FOR MONTHS
PRIOR TO AUGUST 1982) AND ATTENDING
SECONDARY SCHOOL
• DISABLED OR HANDICAPPED (age 18 or over and
disability began before age 22)
FULL NAME OF CHILD

Disabled

CHD2;
CHPE

The Worker's 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 Worker. For a living Worker, the
information below applies to this month or to any of the past 12 months. For a deceased Worker, the information below
applies to the date of death or for any period since the Worker's death. Also list any student who is between the ages of
18 and 23 if the student was both: 1) previously entitled to Social Security benefits on any Social Security record for
August 1981, and 2) was also in full-time attendance at a post-secondary school for May 1982.

Student

3.

CHD2

/

/

/

/

/

/

/

/

/

/

/

/

If you do not wish to be payee for any child or dependent grandchild named above, list the child's name and address in
"Remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits.
4.

If any children in item 3 are stepchildren of the Worker, enter the
date the Worker married the natural parent.

5.
(a) Is there a legal representative (guardian, conservator, curator,
etc.) for any of the children in item 3?
Form SSA-4-BK (02-2006) EF (02-2006) Destroy Prior Editions

Page 1

MONTH, DAY, YEAR

Yes
(If "Yes," complete
(b) and (c).)

No
(If "No," go on to
item 6.)
(over)

(b) Write the following
information about the
legal representative(s):

NAME (First name, middle initial, last name)

TELEPHONE NUMBER
(INCLUDE AREA CODE)

ADDRESS

(c) Briefly explain the circumstances which led the court to appoint a legal representative.

6.

Are you the natural or adoptive parent of the person(s) for whom you are
filing?

7.

Have any children in item 3 ever been adopted by someone other than the
Worker? (If "Yes," enter the following information):
Name of Child
Date of Adoption

8.

Are all the children in item 3 now living in the same household with you? (If
"No," enter the following information about each child not living with you. If
uncertain as to the whereabouts of any of these children, explain in
"Remarks".)

No

Yes

No

Name of Person Adopting

Yes

No

Person With Whom Child Now Lives

Name of Child Not Living With You

9.

Yes

Name and Address

Has any child in item 3 ever been married?
(If "Yes," enter the information requested below.)

Relationship to Child

Yes

No

Name of Child

Date of Marriage (Month, day, year)

How Marriage Ended (If still married, write "not ended").

Date Marriage Ended (Month, day, year)

10. Has anyone ever before filed an application with the Social Security
Administration for monthly benefits on behalf of any child in item 3? (If
"Yes," enter below the name(s) of the child(ren) and the name(s) and Social
CHPE Security number(s) of the person(s) on whose earnings record any other
claim was based.)
Name of Child

Form SSA-4-BK (02-2006) EF (02-2006)

Name of Worker

Yes

No

Social Security Number of Worker

Page 2

/

/

/

/

/

/

/

/

If you are applying ONLY for a child age 18 or over who is disabled, omit items 11 through 14. In all other cases, answer items
11 through 14.
EARNINGS INFORMATION FOR LAST YEAR (Do not complete if the Worker died this year)
11.
(a) Did any child in item 3 earn more than the exempt amount last year? (If
Yes
No
"Yes," answer (b). If "No," go on to item 12.)
(b)

NAME OF CHILD WHO EARNED
OVER THE EXEMPT AMOUNT
LAST YEAR

LIST EACH MONTH THAT CHILD DID NOT EARN

TOTAL EARNINGS
OF CHILD

MORE THAN $

IN WAGES AND DID NOT

PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

$
$
$
EARNINGS INFORMATION FOR THIS YEAR

12. (a) Do you expect the total earnings of any child in item 3 to be more than
the exempt amount this year? (Count all earnings beginning with the first
of this year and all anticipated earnings through the end of this year.) (If
"Yes," answer (b). If "No," go on to item 13.)
(b)

NAME OF CHILD WHO EXPECTS
TO EARN OVER THE
EXEMPT AMOUNT THIS YEAR

EXPECTED EARNINGS
OF CHILD

Yes

No

LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD
DID NOT OR WILL NOT EARN MORE THAN $

IN WAGES AND DID

NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

$
$
$
Complete item 13 ONLY if any child is now in the last 4 months of the child's taxable year (Sept., Oct., Nov., and Dec., if the
taxable year is a calendar year).
EARNINGS INFORMATION FOR NEXT YEAR
13.
(a) Do you expect the total earnings of any child in item 3 to be more than
the exempt amount next year? (If "Yes," answer (b.) If "No," go on to
Yes
No
item 14.)
(b)

NAME OF CHILD WHO EXPECTS
TO EARN OVER THE
EXEMPT AMOUNT NEXT YEAR

LIST EACH MONTH THAT CHILD WILL NOT EARN

EXPECTED EARNINGS
OF CHILD

MORE THAN $

IN WAGES AND WILL NOT

PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

$
$
$
14. If any of the children for whom you are filing uses a fiscal year (one that does NAME OF CHILD AND MONTH FISCAL YEAR ENDS
not end on December 31), print here the name of the child and the month the
fiscal year ends.
Complete items 15 and 16 ONLY if the Worker is living. Otherwise, go on to item 17.
15. If any children in item 3 are children adopted by the Worker, print below the name of each such child and the date of
adoption by the Worker.
NAME OF ADOPTED CHILD

Form SSA-4-BK (02-2006) EF (02-2006)

DATE OF ADOPTION

Page 3

(Turn to page 4)

16. Have all of the children in item 3 lived with the Worker during each of the
last 13 months (counting the present month)?
(If "No," enter the information requested below.)

CHD2
CHPE

NAME OF CHILD WHO DID NOT
LIVE WITH THE WORKER IN EACH
OF THE LAST 13 MONTHS

Yes

No

PERSON WITH WHOM CHILD LIVED

LIST EACH MONTH IN WHICH
THIS CHILD DID NOT
LIVE WITH THE WORKER

NAME AND ADDRESS

RELATIONSHIP TO CHILD

Answer items 17 and 18 only if the child is age 13 or over as of the date of this application.
17. Do any of the children in item 3 have an unsatisfied felony warrant for
his/her arrest?

Yes

No

18. Do any of the children in item 3 have an unsatisfied Federal or State warrant
for his/her arrest for violating the conditions of his/her probation or parole?

Yes

No

Yes

No

19. If any of the children in item 3 are within 2 months of age 65 or older, blind
or disabled, do you want to file on his/her behalf for Supplemental Security
CHD1 Income?

PART II-INFORMATION ABOUT THE DECEASED. Complete items 20 through 28 only if the Worker is deceased.
MONTH, DAY, YEAR

20. (a) Print date of birth of Worker
(b) Print Worker's name at birth if different from item 1 (a)
(c) Check (X) one for the Worker
21.

Male
MONTH, DAY, YEAR

(a) Print date of death

CITY AND STATE

(b) Print place of death
22.

23.
24.

Female

Print the name of the state or foreign country where the Worker had a fixed,
permanent home at the time of death.
Did the Worker work in the railroad industry for 5 years or more?
(a) Was the Worker 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?

STATE OR FOREIGN COUNTRY

Yes
Yes
(If "Yes," answer (b)
and (c).)
FROM (month -year)

(b) Enter dates of service
(c) Has anyone (including the Worker) received, or does anyone expect to
receive, a benefit from any other Federal agency?
25.
(a) Did the worker have social security credits (for example, based on work
or residence) under another country's social security system?

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

No
No
(If "No," go on
to item 25.)
TO (month -year)

No
No
(If "No," go
on to item 26.)

(b) List the country(ies).
26.
(a) Did the worker have wages or self-employment income covered under
Social Security in all years from 1978 through last year?
(b) List the years from 1978 through last year in which the worker
did not have wages or self-employment income covered under
Social Security.
Form SSA-4-BK (02-2006) EF (02-2006)

Page 4

Yes
(If "Yes," skip
to item 27.)

No
(If "No,"
answer (b.).)

Answer item 27 ONLY if death occurred within the last 2 years.
27. (a) About how much did the Worker earn from employment and selfemployment during the year of death?

29.

$
AMOUNT

(b) About how much did the Worker earn the year before death?
28.

AMOUNT

$

Check if applicable:
I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these earnings will be included automatically within 24 months, and any increase in my benefits
will be paid with full retroactivity.
(a) Did the Worker ever file an application for Social Security benefits, a
period of disability under Social Security, Supplemental Security Income,
or hospital or medical insurance under Medicare?

Yes

No

(If "Yes," answer (b) and (c).) (If "No" or
"Unknown," go on to item 30.)

(b) Enter name of person(s) on whose Social Security record other application
was filed.
(c) Enter Social Security number of person named in (b). (If "Unknown," so
/
indicate.)
Answer item 30 ONLY if the Worker died prior to age 66 and within the past 4 months.
30.
(a) Was the Worker unable to work because of a disabling condition at the
Yes
time of death?
(If "Yes," answer (b).)

Were all the children in item 3 living with the Worker at the time of death? (If
"No," enter the following information)
NAME OF CHILD NOT LIVING
WITH THE WORKER

/
No

MONTH, DAY, YEAR

(b) Enter date disability began
31.

Unknown

Yes

No

PERSON WITH WHOM CHILD WAS LIVING
NAME AND ADDRESS

RELATIONSHIP TO CHILD

REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.)

Form SSA-4-BK (02-2006) EF (02-2006)

Page 5

Con't Remarks

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. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a
crime and may be sent to prison, or may face other penalties, or both.
DATE (Month, day, year)

SIGNATURE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

TELEPHONE NUMBERS(S) AT WHICH YOU MAY BE
CONTACTED DURING THE DAY (INCLUDE AREA CODE)

SIGN
HERE

FOR
OFFICIAL
USE ONLY

(AREA CODE)

Routing Transit Number

Direct Deposit Payment Address (Financial Institution)
C/S Depositor Account Number

No Account
Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)

City and State

ZIP Code

County (if any) in which you now live

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. Also, print the applicant's name in the signature
block.
1. Signature of Witness

2. Signature of Witness

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

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

Form SSA-4-BK (02-2006) EF (02-2006)

Page 6

Collection o f Use o f Information From Your Application

- Privacy Act NoticelPaperwork A c t Notice

The Social Security Administration is authorized t o collect the information requested on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration t o determine if you or a dependent is eligible t o insurance coverage and/or monthly benefits. You
do not have t o give us the requested information. However, if you do not provide the information, w e will be
unable t o make an accurate and timely decision concerning your entitlement or a dependent's entitlement t o
benefit payments.
The information you provide may be disclosed t o another Federal, State, or local government agency for
determining eligibility for a government benefit or program, t o a Congressional office requesting information on
your behalf, t o an independent party for the performance of research and statistical activities, or t o the
Department of Justice for use for use in representing the Federal government.
We may also use this information when w e 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 t o
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 t o it.
Explanations about these and other reasons why information you provide may be used or given out are available in
Social Security offices. If you want t o learn more about this, contact any Social Security office.
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Form SSA4-BK (02-2006)
EF (02-2006)

Page 7

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY CHILD'S INSURANCE BENEFITS
SSA OFFICE
DATE CLAIM RECEIVED
BEFORE YOU RECEIVE A
NOTICE OF AWARD

TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO REPORT

(AREA CODE)
AFTER YOU RECEIVE A
NOTICE OF AWARD
(AREA CODE)

Your application for Social Security benefits on behalf of the
child(ren) named below has been received. You will be
notified by mail as soon as a decision is made on your claim.
You should hear from us within
days after you
have given us all the information we requested. Some claims
may take longer if additional information is needed.

In the meantime, if you or any child(ren) changes address, or
if there is some other change that may affect your claim, you
or someone for you should report the change. The changes
to be reported are listed below.
Always give us your claim number when writing or
telephoning about your claim.
If you have any questions about your claim, we will be glad
to help you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

WORKER'S NAME (If surname differs from name of claimant(s).)

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID AND IN POSSIBLE MONETARY PENALTIES
The child age 13 or older has an unsatisfied warrant for a
You or any child changes mailing address for checks or
violation of probation or parole under Federal or State law.
residence. (To avoid delay in receipt of checks you
A student, age 18 or over, stops attending school,
should ALSO file a regular change of address notice with
reduces school attendance below full-time, changes
your post office.)
schools, or is paid by an employer to attend school.
Any child's citizenship or immigration status changes.
If the worker and stepchild's parent divorce. Benefits are
Any beneficiary goes outside the U.S.A. for 30
not payable to a stepchild beginning with the month after
the month the worker and the stepchild's parent divorce.
consecutive days or longer.
Promptly return any benefit payment received on behalf of
Any beneficiary dies or becomes unable to handle
the stepchild for the months after the month the divorce
benefits.
becomes final.
Work Changes - On your application you told us
The child is confined to jail, prison, penal institution or
expected total earnings for
correctional facility for conviction of a crime or confined to
(Name of Child)
a public institution by court order in connection with a
crime.
to be $
.
(Name of Child)

(is)

more than $
(Name of Child)

(is not) earning wages of
a month.

(is)

(is not) self-employed

rendering substantial services in a trade or business.
(Report AT ONCE if this work pattern changes.)
Custody Change - Report if a child for whom you are
filing or who is in your care dies, leaves your care or
custody, or changes address.
The child age 13 or older has an unsatisfied warrant for
their arrest for a crime or attempted crime that is a
felony (or in jurisdictions that do not define crime as
felonies, a crime that is punishable by death or
imprisonment for a term exceeding 1 year).
Form SSA-4-BK (02-2006) EF (02-2006)

Change of Marital Status- Marriage, divorce, or
annulment of marriage. You must report marriage even if
you believe that an exception applies.
Disability Applicants
In addition to the applicable reporting requirements listed
above:
1. The disabled adult child returns to work (as an
employee or self-employed) regardless of amount of
earnings.
2. The disabled adult child's condition improves.
An agency in your State that works with us in
administering the Social Security disability program is
responsible for making the disability decision on the
child's claim. In some cases, it is necessary for them to
get additional information about the child's condition or
to arrange for the child to have a medical examination at
Government expense.
Page 8

HOW TO REPORT
You can make your reports by telephone, mail, or in person, whichever you prefer.
If you are awarded benefits and one or more of the above change(s) occur, you should report by:
Calling us TOLL FREE at 1-800-772-1213;
If you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social Security office at the phone number and address above.
For general information about Social Security, visit our web site at www.socialsecurity.gov.
For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 month and 15
days after the end of any taxable year in which the child earns more than the annual exempt amount. You may contact
SSA to file a report for the child. Otherwise, SSA will use the earnings reported by the child's employer(s) and the child's
self-employment tax return (if applicable) as the report of earnings required by law, to adjust benefits under the earnings
test. It is your responsibility to ensure that the information you give concerning the child's earnings is correct.

Form SSA-4-BK (02-2006) EF (02-2006)

Page 9

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 9 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 9 to 15
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. To find the nearest office call Social Security at 1-800-772-1213 (TTY 1800-325-0778). Send&o comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401