Form SSA-4-BK Application for Child's Insurance Benefits

Form SSA-4-BK (01-2017) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 9
0MB No. 0960-0010

□ TEL

(Do not write in this space)

APPLICATION FOR CHILD'S INSURANCE BENEFITS
With this application, you are applying 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").

D Life

Claim

D Death
Claim

FIRST NAME, MIDDLE INITIAL, LAST NAME

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

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

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) PRINT your Social Security number.

PART 1 - INFORMATION ABOUT THE WORKER'S CHILDREN
3.

The Worker's children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including
step grandchildren) 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.
List below all children who are:
• Under age 18
• Age 18 to 19 and attending elementary
or secondary school full-time
f--9i58bled-or-Handicappetl"fa]'e-ta""Or
vef-Sfl &eisabHity-begantrefore
-a�Z')-

• 15.o.e.. \8 or ok:ier "'1•�

CL

FULt'NAME OF CHILD (J:, sa.b', \ ;+'-/

Check
(X)
Sex of
Child

M

cl

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

F

�o.+ b�qa.A □ □
be+-urL
O.Q

4.
5.

e...

2-2-.

□□
□
□□
□□
□□

Check (X) the
Check
(X) if .._ Column That
Child �Shows Child's
17.5 or 1Relationship to
CHILD'S SOCIAL
Worker
Older is:
SECURITY NUMBER
'2
--o
C:"O \
'C ;g a,·C:
Q)
Q) .c "O
:0
ci. C. C: (.) Q)
"O
ro

-

�.!l

I

f

.c

0

(.)

u5

o

□
□
□
□
□
□

□ □□□
□ □□□
□ D□□
D □□D
□ □□□
□ □□□

Cl)

�

Q)

u5

Q) "O
C. C:
Q) �

0

□
□
□
□
□
□

□
□

Oc.9

D

□
□
□

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

(a) Is there a legal representative (guardian, conservator, curator,
etc.) for any of the children in item 3?

MONTH, DAY, YEAR

□ Yes

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

□ No

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

Form SSA-4-BK (01-2017) UF

5.

Page 2 of 9

(b) Write the
NAME (First name, middle initial, last name)
following information
about the legal
ADDRESS
representative( s):

TELEPHONE NUMBER
(INCLUDE AREA CODE)

(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?

D

Yes

□

No

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

D

Yes

□

No

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".)
Name of Child Not Living
With You

9.

10.

Name of Person Adopting

D

Yes

Person With Whom Child Now Lives
Name and Address

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

D

Yes

0

No

Relationship to Child

0

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)

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 Security number(s) of the person(s) on whose earnings record
any other claim was based.)
Name of Child
Name of Worker

D

Yes

0

No

Social Security Number of Worker

Form SSA-4-BK (01-2017) UF

Page 3 of 9

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," answer (b). If "No, " go on to item 12.)
(b)
NAME OF CHILD WHO
EARNED OVER THE EXEMPT
AMOUNT LAST YEAR

TOTAL EARNINGS
OF CHILD

I

D Yes

□ No

LIST EACH MONTH THAT CHILD DID NOT EARN 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
□ Yes
□ No
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)
LIST EACH MONTH (INCLUDING THE PRESENT MONTH)
NAME OF CHILD WHO
EXPECTED
THAT CHILD DID NOT OR WILL NOT EARN MORE THAN
EXPECTS TO EARN OVER THE
EARNINGS OF
$
IN WAGES AND DID NOT OR WILL NOT
EXEMPT AMOUNT THIS YEAR
CHILD
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 item 14.)
(b)

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

EXPECTED
EARNINGS OF
CHILD

□ Yes

□ No

LIST EACH MONTH THAT CHILD WILL NOT EARN MORE
THAN$
IN WAGES AND WILL NOT PERFORM
SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

$
$
$
If any of the children for whom you are filing uses a fiscal year (one that Name of child and month fiscal year ends
does 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 1f 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
DATE OF ADOPTION
14.

Form SSA-4-BK (01-2017) UF
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.)
NAME OF CHILD WHO
DID NOT LIVE WITH THE
WORKER IN EACH OF
THE LAST
13 MONTHS

17.

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

Page 4 of 9
OYes

ONo

PERSON WITH WHOM CHILD LIVED
RELATIONSHIP TO
CHILD

NAME AND ADDRESS

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 Income?

O Yes

ONo

PART II - INFORMATION ABOUT THE DECEASED. Complete items 18 through 26 only if the Worker is deceased.
18.

MONTH, DAY, YEAR

(a) Print date of birth of Worker
(b) Print Worker's name at birth if different from item 1 (a)

□ Male

(c) Check (X) one for the Worker
19.

(a) Print date of death

MONTH, DAY, YEAR
CITY AND STATE

(b) Print place of death
20.

Print the name of the state or foreign country where the Worker had a
fixed, permanent home at the time of death.

21 .

Did the Worker work in the railroad industry for 5 years or more?

22.

(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
OYes

O No

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

(b) Enter dates of service

23.

0 Female

O No
(If "No," go
on to item 23.)
TO (month-year)

I

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

OYes

O No

(a) Did the worker have social security credits (for example, based on
work or residence) under another country's social security system?

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

O No
(If "No," go
on to item 24.)

(b) List the country(ies) .
24.

□ Yes

(a) Did the worker have wages or self-employment income covered
under Social Security in all years from 1978 through last year?

(If "Yes", skip to
item 25.l

(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.
Answer item 25 ONLY if death occurred within the last 2 years.
25.

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

AMOUNT
$

AMOUNT
$

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

Form SSA-4-BK (01-2017) UF
26.

27.

Page 5 of 9

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

D

□ No

Unknown

(If "Yes," answer (b) and (c).)
(If "No" or "Unknown ," go on to item 28.)

(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.) D
Answer item 28 ONLY if the Worker died prior to age 66 and within the past 4 months.

28.

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

O No

(If "Yes," answer (b).)
MONTH, DAY, YEAR

(b) Enter date disability began
29.

□ Yes

(a) Was the Worker unable to work because of a disabling condition at
the time of death?

O Yes

O No

PERSON WITH WHOM CHILD WAS LIVING
NAME AND ADDRESS

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

RELATIONSHIP TO
CHILD

Form SSA-4-BK (01-2017) UF

Page 6 of9

Can'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
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a
fine or imprisonment.
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 (Include
Area Code)

Direct Deposit Payment Information (Financial Institution)
Routing Transit Number

D
D

Account Number

~pplicant's..~ai!ing Address (Number and~
Remarks, tf different.)
S

Checking
Savings

D
D

Enroll in Direct Express
Direct Deposit Refused

t. Apt No., P. 0. Box, or Rural Route) (Enter Residence Address in

( C..G.f; -h,;.. \ i 2.- e)

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 (01-2017) UF

Page 7 of 9

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy
Act Statement

Sections 202, 205, 223, 1818, 1836, and 1840 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely decision on any claim filed, or could result in the loss of
benefits.
We will use the information you provide to determine eligibility for monthly benefits or insurance coverage
and to authorize payments to the children of retired, disabled, or deceased workers. We may also share
your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash
income maintenance or health maintenance programs (including programs under the Act).
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting 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.
3. To the Centers for Medicare & Medicaid Services, for the purpose of administering Medicare Part
A , Part B, Medicare Advantage Part C, and Medicare Part D.
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 Folder System, and 60-0321 , entitled Medicare Database (MOB) File. Additional information
and a full listing of all our SORNs are available on our website at www.socic3.lsecurity.gov/foia/b[11_eb.o0Js.

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 (0MB) control number.
We estimate that it will take about 12 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-4-BK (01-2017) UF

Page 8 of9

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

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

SSA OFFICE

DATE CLAIM RECEIVED

AFTER YOU RECEIVE A
NOTICE OF AWARD

Your appl1cat1on 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.

In the meantime, If you or any ch1ld(ren) changes address, or 1f
there is some other change that may affect your claim, you or
someone for you should report th._e chang_e. The changes to be
reported are listed-below-,. on Pa.'je. '1.

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

CLAIMANT

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

SOCIAL SECURITY CLAIM NUMBER

Form SSA-4-BK (01-2017) UF

Page 9 of 9

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID
AND IN POSSIBLE MONETARY PENALTIES
• You or any child changes mailing address for checks or
e(Jr- • A student, age 18 or over, stops attending school,
residence. To avoid delay in receipt of check~ u--- 1nS
c- reduces school attendance below full-time, changes
should ALSO file a regular change of address notice
CP('('C"'I
schools, or is paid by an employer to attend school.
with your post office.
• If the worker and stepchild's parent divorce. Benefits
• Any child's citizenship or immigration status changes.
are not payable to a stepchild beginning with the
month after the month the worker and the
• Any beneficiary goes outside the U.S.A. for 30
stepchild's parent divorce. Promptly return any
consecutive days or longer.
benefit payment received on behalf of the stepchild
for the months after the month the divorce
• Any beneficiary dies or becomes unable to
becomes final.
handle benefits.
• The child is confined for more than 30 continuous
• Work changes - On your application you told us
days to a jail, prison, penal institution or correctional
facility for conviction of a crime or confined to a
- - - - - - - -- -- - expected total earnings
(Name of Child)
public institution by a court order in connection with
a
crime.
for
- - - - to be$ - - -- - - (Year)
• Change in Marital Status - Marriage, divorce, or
O(is) O(is not) earning
annulment of marriage. You must report marriage
- - -(Name
- - -of-- -Child)
even if you believe that an exception applies.
wages of more than$

------

- - -(Name
- --of---Child)

O (is)

a month.

D (is not) self-employed

and 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 felony or arrest
warrant for more than 30 continuous days for flight to avoid
prosecution or confinement, escape from custody, or flightescape.

• 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.

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:

,, tr-.'( So c iC-.\ Sec.,vr;+y '•

•
•
•
•

Visiting the section "~~u-GaA"Bo"'6nline" at our web site at www.socialsecurity.gov;
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, visitipgpf\Writing your local Social Security office at the phone number and address-above,- -5 own O"' . 'JOU
I....__'._../ , "s er
~ ma...
c.,1 0 ; ()\. r-e c e
For general information about Social Security, visit our web site at www.socialsecurity..l!OV.

h

+

,p+ •

For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 months 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 responsibi lity to
ensure that the information you give concerning the child's earnings is correct.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 202(d) 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 an accurate and timely decision on any claim filed.
We will use the information to determine eligibility for monthly benefits or insurance coverage
and to authorize payments to the child(ren) of retired, disabled, or deceased workers. We may
also share your information for the following purposes, called routine uses:
•

To Federal, State, or local agencies for administering cash or non-cash income or health
maintenance programs; and

•

To a contractor or another Federal agency, as necessary for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.

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 System, 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.