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

Application for Child's Insurance Benefits

screens for ssa-4 (3)

Application for Child's Insurance Benefits / Life Claim / MCS and PCS

OMB: 0960-0010

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0010 can be found here:

2022-10-24 - Revision of a currently approved collection

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MCS 3.7 CHILD'S IDENTIFICATION 1 CHD1

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

[1-C] [2-C] [3-C]

BIRTH CITY: XXXXXXXXXXXXXXX BIRTH STATE: XX BIRTH COUNTRY: XX

[4-M]

HAS ANYONE EVER FILED ON CHILD'S BEHALF FOR BENEFITS (Y/N) X

[5-C]

IF YES, NH FIRST NAME: XXXXXXXXXXXXXXX MI: X LAST: XXXXXXXXXXXXXXXXXXXX

[6-C] [7-C]

NH SSN: XXXXXXXXX STAT: XX

[8-C]

IF AGE 16 OR OLDER, LANGUAGE SPOKEN AND WRITTEN IS ENGLISH (Y/N): P

[9-C]

IF OVER 16 IS CHILD DISABLED (Y/N): X

[10-C]

FILING AS DISABLED CHILD ON THIS ACCOUNT (Y/N): X

[11-C]

IF YES, ONSET DATE: 99999999

[12-C]

WILL MEDICARE APPLY: 9 1. YES 2. NO 3. ALREADY ENROLLED

[13-C]

IF ALREADY ENROLLED, SSN: 999999999

[14-M]

SELECT FILED OR INTEND TO FILE FOR SSI: 9

1. YES

2. NOT DISABlED, BLIND, OR WITHIN 2 MONTHS OF AGE 65 OR OLDER

3. DOES NOT WISH TO FILE

[15-C]

IF AGE 17 AND 6 MONTHS, IS CHILD A STUDENT (Y/N) X

[16-M]

WORK LAST YEAR THIS YEAR NEXT YEAR (Y/N): X

[17-M]

EVER MARRIED (Y/N): X

TRANSFER TO: XXXX

COMM child relationship cRel

[1-D] [2-D] [3-D]

NH: SSSSSSSSS SSSSS SSSSSSSSSS BN: SSSSSSSSS SSSSS SSSSSSSSSS PIC: SSS

BIRTH CITY: SSSSSSSSSSSSSSS BIRTH STATE: SS BIRTH COUNTRY: SS

[4-C]

date dependency met (MMDDCCYY): 99999999

[5-M] [6-M]

*child relationship begin date (mmddccyy): 99999999 *Proof (y/n): x

[7-M]

*Select rElationship type: 9 1=natural legitimate 6=stepchild

2=legitimated child 7=stepchild (216K)

3=adopted child 8=inheritance rights

4=equitably adopted 9=other (216H3)

5=grandchild.

[8-O]

child relationship end dATE (MMDDCCYY): 99999999

[9-C]

select relationship end reason: 9

1=parent divorced nh 3=prospective annulment of parent marriage – voidable

2=annulment of adoption 4=ab initio annulment of parent marriage- voidable

5=ANNULMENT OF PARENT MARRIAGE – VOID

6=CHANGE OF RELATIONSHIP.

[10-O]

DELETE THIS OCCURRENCE OF DATA (Y/N): x

[11-O] [12-O]

ADD NEW OCCURRENCE (Y/N): x REVIEW PRIOR OCCURRENCES (Y/N): x

[13-D] [14-O]

PF1 HELP AVAILABLE TRANSFER TO: XXXX

MCS 3.3 TRANSFER TO: XXXX CHILD'S IDENTIFICATION 2 CHD2

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

[1-M]

IF NOT LIVING WITH NH ANY OF LAST 13 MTHS OR AT TIME OF DTH SHOW MTHS

YR: ALL O1 02 03 04 05 06 07 08 09 10 11 12

99 X X X X X X X X X X X X X

YR: ALL 01 02 03 04 05 06 07 08 09 10 11 12

99 X X X X X X X X X X X X X

[2-C]

IF NOT LIVING WITH NH, WAS CHILD LIVING WITH APPLICANT? (Y/N)

[3-C]

IF No CHILD LIVED WITH:

NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[4-C]

ADDRESS 1: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 2: XXXXXXXXXXXXXXXXXXXXXX

ADDRESS 3: XXXXXXXXXXXXXXXXXXXXXX ADDRESS 4: XXXXXXXXXXXXXXXXXXXXXX

[5-C]

IF ADOPTED, NAME OF PERSON ADOPTING IF OTHER THAN NH:

FIRST: XXXXXXXXXX MI: X LAST: XXXXXXXXXXXXXXXXXXX

MCS 3.7 CHILD’S POTENTIAL ENTITLEMENT CHPE

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSS SSSSSSSSSS

[1-M]

CHILD POTENTIALLY ENTITLED ON ADOPTIVE, STEP OR OTHER PARENT RECORD (Y/N): X

[2-M]

CHILD POTENTIALLY ENTITLED ON A GRAND OR STEP GRANDPARENT RECORD (Y/N): X

LIST THE NAME AND SSN CHILD POTENTIALLY ENTITLED

[3-C] [4-C]

FIRST NAME MI LAST NAME SSN

XXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX XXXXXXXXX

TRANFER TO: XXXX

MCS 2.5 TRANSFER TO: XXXX DEPENDENT CHILDREN OF NH DEPC

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

LIST ALL CHILDREN OF NH: UNDER 18

18-19 AND ATTENDING SECONDARY SCHOOL

[1-M] DISABLED/HANDICAPPED PRIOR TO 22

NAME:

XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

COMM CITIZENSHIP (U.S. AND/OR FOREIGN) CLCZ

[1-D] [2-D] [3-D]

NH: SSSSSSSSS SSSSS SSSSSSSSSS BN: SSSSSSSSS SSSSS SSSSSSSSSS PIC: SSS

[4-M]

*COUNTRY/TERRITORY OF CITIZENSHIP: xx

[5-C]

SELECT U.S. TYPE IF CITIZENSHIP COUNTRY IS U.S.: 9

1= BIRTH IN U.S. 2= U.S. CITIZEN BORN OUTSIDE U.S. 3= NATURALIZATION

[6-C]

SELECT U.S. PROOF IF CITIZENSHIP COUNTRY IS U.S.: 9

1= ENUMERATION 4=DEVELOPMENT PENDING

2= TITLE 2/18/16 5=NO PROOF

3= FUTURE USE 6=PRESUMED - SYSTEMS GENERATED ONLY

[7-M]

*CITIZENSHIP START DATE (MMDDCCYY): 999999999

[8-O]

CITIZENSHIP STOP DATE (MMDDCCYY): 999999999

[9-O]

IS LAWFUL PRESENCE DATA NEEDED (Y/N): X

[10-O]

DELETE THIS OCCURRENCE OF DATA (Y/N): X

[11-O] [12-O]

ADD NEW OCCURRENCE (Y/N): X REVIEW PRIOR OCCURRENCES (Y/N): X

[13-D] [14-O]

PF1 HELP AVAILABLE TRANSFER TO: XXXX

MCS CLAIMANT MAILING ADDRESS CADR

NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS

[1-M]

*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP

ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP

[2-M] [3-C] [4-C]

*CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP

[5-C] [6-C]

STATE & COUNTY CODE: PPPPP COUNTY: XXXXXXXXXXXXXX

[7-C] [8-C]

COUNTRY: PPPPPPPPPPPPPPPPPPPPP CONSULAR CODE: PPP

[9-C]

FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

[10-M] [11-M]

*bank account (y/n): x *direct express (y/N): x

[12-C] [13-C]

DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999 ACCOUNT TYPE (C/S): A

[14-C]

DEPOSITOR ACCOUNT NUMBER: 99999999999999999

[15-C] [16-C]

DOMESTIC PHONE: PPPPPPPPPP FOREIGN PHONE: PPPPPPPPPPPPPPP

[17-c]

enter phone code: x 1= home 2= work 3=none 4=unknown 5=other 6=attorney 7=mobile

TRANSFER TO: XXXX CLIENT ADDRESS CLAD

SS SSSSSSSSS SSSSS SSSSSSSSSS

[1-D]

ADDRESS TYPE: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

[2-C]

ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[3-C] [4-C] [5-C]

CITY: PPPPPPPPPPPPPPPPPPP STATE: PP ZIP:PPPPP

[6-C] [7-M]

STATE/COUNTY CODE: PPPPPP DISTRICT OFFICE CODE: PPP

[8-C] [9-C]

FOREIGN COUNTRY: PPPPPPPPPPPPPPPPPPPPPPP FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP

[10-C] [11-C]

CONSULAR CODE: PPP GEOGRAPHIC CODE: PPPPP

[12-M] [13-C] [14-C]

START END N/E

(MMDDYY) (MMDDYY)

PPPPPP PPPPPP X

[15-M] [16-M] [17-M] [18-D]

NEW (Y/N): X DELETE THIS PAGE (Y/N): X EXIT CLAD (Y/N): X SS OF SS

MCS TRANSFER TO: XXXX REMARKS SCREEN RMKS

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

[1-C]

TYPE OF REMARKS

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[2-C] [3-C]

MORE (Y/N): X GO TO RPS (Y/N): X

PAGE S

File Type	application/msword
File Title	MCS 3
Author	084680
Last Modified By	889123
File Modified	2010-03-02
File Created	2010-03-02