Form SSA-24 Application for Survivor's Benefits

Form Approved
OMB Approved No. 0960-0062

SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SURVIVORS BENEFITS

(DO NOT WRITE IN THIS SPACE)

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)
IMPORTANT-- Read instructions before completing form. Detach and retain ONLY the instruction sheet

VA DATE STAMP

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.
3. SOCIAL SECURITY NO. OF VETERAN

4. DATE OF BIRTH

6. NAME OF FATHER

5. PLACE OF BIRTH

8. DID THE VETERAN WORK IN THE RAILROAD
INDUSTRY AT ANY TIME AFTER 1936?

7. MAIDEN NAME OF MOTHER

YES

NO

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the
military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric
Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.
9A. DATE ENTERED ACTIVE SERVICE

9B. SERVICE NO.

10. RELATIONSHIP OF APPLICANT TO VETERAN
SURVIVING SPOUSE OR SURVIVING DIVORCED SPOUSE
PARENT

9C. DATE SEPARATED FROM ACTIVE
SERVICE

11. DATE OF BIRTH OF APPLICANT

9D. GRADE, RANK, OR RATING, ORGANIZATION
AND BRANCH OF SERVICE

12. VA FILE NO.

CHILD

CHILDREN: Show names of surviving children (including adopted children and stepchildren) or dependent grandchildren (including stepgrandchildren)
who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c) disabled or
handicapped (18 or over and disability began before age 22).
13A.

13B.

13C.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a
right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I
have given in this document is true.
14. DATE (Month, day, year)

15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)
SIGN
HERE

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP

17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
20. PROOFS RECEIVED
DEATH

AGE
OTHER (Specify)

21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)
MARRIAGE

DEATH

(NAME)
(NAME)

AGE
OTHER (Specify)

(NAME)
22. DATE

MARRIAGE

(NAME)
(NAME)
(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (2-2002) Destroy All Prior EditionsPAGE 9

Please see revised Paperwork
Reduction Act and Privacy Act
Statements below.

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)
This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the Social Security
Act, as amended. Under authority of section 202(o) of the Social Security Act, the application requests information
in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete part or
all of the SSA-24. However, it is usually to your advantage to provide the information because not providing it
could prevent an accurate and timely decision on your claim or could result in the loss of some benefits or insurance
coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to the Social
Security Administration and used by them to determine whether social security benefits may be payable to surviving
dependent(s) of the veteran. Social Security will then contact you regarding any social security benefits payable
based on information given on this form.
Please understand that Social Security may, in certain instances, disclose the information on this form to another
Federal, State or local agency or individual without your written consent. This would be done in order to:
enable a third party or an agency to assist Social Security in establishing an individual's right to benefits or
coverage;
comply with Federal laws which require or authorize the release of information from social security records;
and
facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
social security programs.
If you should have any question about entitlement to social security benefits or the information you have
provided on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When signed and
dated the form SHOULD BE LEFT ATTACHED to your completed
VA FORM 21-534, Application for Dependency and Indemnity Compensation, Death Pension and
Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) or
VA FORM 21-535, Application for Dependency and Indemnity Compensation by Parent(s)
(Including Accrued Benefits and Death Compensation When Applicable).
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will
take you about 15 minutes to read the instructions, gather the necessary facts, and answer the questions.

PAGE 10

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 15
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

Privacy Act Statement
Collection and Use of Personal Information
Section 202(o) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to determine whether social
security benefits may be payable to survivors of a veteran.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent an accurate and timely decision on your claim or
could result in the loss of some benefits or insurance coverage.
We generally use the information you supply to determine whether social security
benefits may be payable to survivors of a veteran. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routine
uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information about this form, and any other information regarding our systems
and programs, is available on-line at www.socialsecurity.gov or at your local Social
Security office.