Form SSA-24 Application for Survivor's Benefits

Form Approved
OMB Approved No. 0960-0062
SOCIAL SECURITY ADMINISTRATION

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

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

5. PLACE OF BIRTH

6. NAME OF FATHER

7. MAIDEN NAME OF MOTHER

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

CHILD

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.

PARENT

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

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

DEATH
MARRIAGE

DEATH
MARRIAGE

(NAME)

AGE
OTHER (Specify)

AGE

(NAME)

OTHER (Specify)
(NAME)

22. DATE

(NAME)

(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (07-2011) DESTROY PRIOR EDITIONS

Page 9

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.
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 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.

See revised PRA

Privacy Act Statement
See revised Privacy Act
Collection and Use of Personal Information
Section 202(o) of the Social Security Act, as amended, authorizes us to collect this information. We willStatement
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.

Form SSA-24 (07-2011)

Page 10

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
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.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making a correct and timely decision on your claim or could
result in the loss of some benefits or insurance coverage.
We rarely use the information you supply for any purpose other than determining whether social
security benefits may be payable to survivors of a veteran. However, we may use the
information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0090, entitled Master Beneficiary
Record. Additional information about these and other system of records notices and our
programs is available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

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 (OMB) 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.