Form SSA-24 Application for Survivor's Benefits

Form Approved
OMB 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 2. DATE OF DEATH
(Type or print)

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.

9C. DATE SEPARATED
FROM ACTIVE SERVICE

10. RELATIONSHIP OF APPLICANT TO VETERAN
11. DATE OF BIRTH OF
APPLICANT
SURVIVING SPOUSE
CHILD
PARENT
OR SURVIVING
DIVORCED SPOUSE

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

12. VA FILE NO.

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)

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., 17. TELEPHONE NO. (Include Area Code)
State and ZIP)
Form SSA-24 (04-2014)
Destroy Prior Editions

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

20. PROOFS RECEIVED
DEATH

(NAME)

DEATH

MARRIAGE

MARRIAGE
(NAME)

(NAME)

AGE
OTHER (Specify)
22. DATE

(NAME)

AGE
(NAME)

OTHER (Specify)

(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

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).
Form SSA-24 (04-2014)

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See Revised Privacy Act
Privacy Act Statement
Statement Attached
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.
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.

Form SSA-24 (04-2014)

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