Form Ssa 4 Bk – Fill Out and Use This PDF

The SSA-4-BK form is a critical document for applying for Child's Insurance Benefits under Title II of the Social Security Act, which covers federal old-age, survivors, and disability insurance. It is designed for those applying on behalf of a child or children for any insurance benefits for which they may be eligible, based on the earnings record of a living or deceased worker. Should you need to secure benefits for a child, utilizing this form properly is the first step in the process.

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Form Ssa 4 Bk PDF Details

The SSA-4-BK form is a critical document for those seeking to secure Child's Insurance Benefits under Title II of the Social Security Act, which encompasses Federal Old-Age, Survivors, and Disability Insurance. This application facilitates the process for eligible children, including natural, adopted, and stepchildren, as well as dependent grandchildren, to receive benefits based on the earnings record of a living or deceased worker. The form also serves as an application for survivors benefits under the Railroad Retirement Act and for Veterans Administration payments under Veterans Benefits, thus expanding potential assistance beyond social security. Its detailed sections request comprehensive information about the child's relationship to the worker, their residential situation, earning details, and whether previous applications for benefits have been filed. For deceased workers, it gathers essential data regarding the worker's death, military service, and work history, ensuring a thorough evaluation can be completed for entitlement to benefits. Additionally, it addresses the potential need for a legal representative for the child and inquires about any existing conditions that might qualify the child for Supplemental Security Income, underscoring the form’s role in facilitating a broad scope of support for beneficiaries.

Question	Answer
Form Name	Form Ssa 4 Bk
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	social security benefits application form, social security form ssa 4 bk, ssa4 form, social security child insurance

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

Social Security Administration

	Page 1 of 9
TEL	OMB No. 0960-0010

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).

(Do not write in this space)

Life Death

Claim Claim

1. (a) PRINT name of Wage Earner or Self-Employed person FIRST NAME, MIDDLE INITIAL, LAST NAME (herein referred to as the ''Worker'').

(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:

Check

Check (X) the

(X) if

Column That

(X)

Child

Shows Child's

Sex of

• Under age 18

17.5

Relationship to

Child

Date of Birth

CHILD'S SOCIAL

Older is:

Worker

• Age 18 to 19 and attending elementary

(Mo., day, yr.)

SECURITY NUMBER

or secondary school full-time

Student

Disabled

Legitimate

Adopted

Stepchild

Dependent Grandchild

Other

• Disabled or Handicapped (age 18 or

over and disability began before

age 22)

FULL NAME OF CHILD

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.

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

5.	(a) Is there a legal representative (guardian, conservator, curator,	Yes	No
	etc.) for any of the children in item 3?	(If "Yes," complete	(If "No," go on to
		(If "Yes," complete	(If "No," go on to
		(b) and (c).)	item 6.)

Form SSA-4-BK (01-2017) UF			Page 2 of 9

5. (b) Write the		NAME (First name, middle initial, last name)	TELEPHONE NUMBER
	following information		(INCLUDE AREA CODE)
	about the legal
	about the legal	ADDRESS
	representative(s):	ADDRESS
	representative(s):

6.	Are you the natural or adoptive parent of the person(s) for whom you		Yes	No
	are filing?		Yes	No
	are filing?
7.	Have any children in item 3 ever been adopted by someone other than		Yes	No
	the Worker? (If "Yes," enter the following information):		Yes	No
	the Worker? (If "Yes," enter the following information):

	Name of Child	Date of Adoption	Name of Person Adopting

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		Yes	No
	with you. If uncertain as to the whereabouts of any of these children,		Yes	No

	explain in "Remarks".)

	Name of Child Not Living	Person With Whom Child Now Lives
	With You
	With You	Name and Address		Relationship to Child

9.	Has any child in item 3 ever been married?	Yes	No
	(If "Yes," enter the information requested below.)	Yes	No
	(If "Yes," enter the information requested below.)

	Name of Child	Date of Marriage (Month, day, year)

	How Marriage Ended (If still married, write "not ended").	Date Marriage Ended (Month, day, year)

10.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		Yes	No
Social Security number(s) of the person(s) on whose earnings record
any other claim was based.)

Name of Child	Name of Worker	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?					Yes	No
	(If "Yes," answer (b). If "No," go on to item 12.)					Yes	No
	(If "Yes," answer (b). If "No," go on to item 12.)

	(b) NAME OF CHILD WHO	TOTAL EARNINGS	LIST EACH MONTH THAT CHILD DID NOT EARN MORE
	EARNED OVER THE EXEMPT	TOTAL EARNINGS	THAN $			IN WAGES AND DID NOT PERFORM
	EARNED OVER THE EXEMPT	OF CHILD	THAN $			IN WAGES AND DID NOT PERFORM
	AMOUNT LAST YEAR	OF CHILD	SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT
	AMOUNT LAST YEAR		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.)					Yes	No

	(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		Yes	No
	on to item 14.)

	(b)	NAME OF CHILD WHO	EXPECTED	LIST EACH MONTH THAT CHILD WILL NOT EARN MORE
		NAME OF CHILD WHO	EXPECTED	LIST EACH MONTH THAT CHILD WILL NOT EARN MORE
	EXPECTS TO EARN OVER THE		EARNINGS OF	THAN $		IN WAGES AND WILL NOT PERFORM
	EXEMPT AMOUNT NEXT YEAR		CHILD	SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT

			$

			$

			$

14. 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 if 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

18. (a) Print date of birth of Worker

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

Page 4 of 9

16.

Have all of the children in item 3 lived with the Worker during each of
the last 13 months (counting the present month)?			Yes	No
(If "No," enter the information requested below.)

NAME OF CHILD WHO	LIST EACH MONTH IN WHICH		PERSON WITH WHOM CHILD LIVED
DID NOT LIVE WITH THE			PERSON WITH WHOM CHILD LIVED
DID NOT LIVE WITH THE
WORKER IN EACH OF	THIS CHILD DID NOT			RELATIONSHIP TO
THE LAST	LIVE WITH THE WORKER	NAME AND ADDRESS		RELATIONSHIP TO
THE LAST	LIVE WITH THE WORKER	NAME AND ADDRESS		CHILD
13 MONTHS				CHILD
13 MONTHS

17.

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?

Yes

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

MONTH, DAY, YEAR

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

	(c) Check (X) one for the Worker	Male	Female

19.	(a) Print date of death	MONTH, DAY, YEAR

	(b) Print place of death	CITY AND STATE
	(b) Print place of death

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

21.	Did the Worker work in the railroad industry for 5 years or more?	Yes	No

22.	(a) Was the Worker in the active military or naval service (including	Yes	No
	Reserve or National Guard active duty or active duty for training)	(If "Yes," answer	(If "No," go
	after September 7, 1939 and before 1968?	(b) and (c).)	on to item 23.)

	(b) Enter dates of service	FROM (month-year)	TO (month-year)
	(b) Enter dates of service

	(c) Has anyone (including the Worker) received, or does anyone	Yes	No
	expect to receive, a benefit from any other Federal agency?	Yes	No
	expect to receive, a benefit from any other Federal agency?

23.	(a) Did the worker have social security credits (for example, based on	Yes	No
	work or residence) under another country's social security system?	(If "Yes,"	(If "No," go
		answer (b).)	on to item 24.)
		answer (b).)	on to item 24.)
	(b) List the country(ies).

24.	(a) Did the worker have wages or self-employment income covered	Yes	No
	under Social Security in all years from 1978 through last year?	(If "Yes", skip to	(If "No," answer
		item 25.)	(b).)
		item 25.)	(b).)

(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	AMOUNT
	(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
		$
		$

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

Page 5 of 9

26.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.

27. (a) Did the Worker ever file an application for Social Security benefits, a		Yes	No	Unknown
	period of disability under Social Security, Supplemental Security	(If "Yes," answer (b) and (c).)
	Income, or hospital or medical insurance under Medicare?	(If "Yes," answer (b) and (c).)
	Income, or hospital or medical insurance under Medicare?	(If "No" or "Unknown," go on to item 28.)
		(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.)

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

28.

29.

(a) Was the Worker unable to work because of a disabling condition at		Yes	No
the time of death?		(If "Yes," answer (b).)

(b) Enter date disability began		MONTH, DAY, YEAR
(b) Enter date disability began

Were all the children in item 3 living with the Worker at the time of death?		Yes	No
(If "No," enter the following information)		Yes	No
(If "No," enter the following information)

NAME OF CHILD NOT LIVING	PERSON WITH WHOM CHILD WAS LIVING

			RELATIONSHIP TO
WITH THE WORKER	NAME AND ADDRESS		RELATIONSHIP TO
WITH THE WORKER	NAME AND ADDRESS		CHILD
			CHILD

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

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ssa 4 writing process described (stage 1)

2. Once your current task is complete, take the next step – fill out all of these fields - FULL NAME OF CHILD, M F, g e L, h c p e S, n e d n e p e D, h c d n a r G, If you do not wish to be payee for, If any children in item are, MONTH DAY YEAR, a Is there a legal representative, Yes, If Yes complete, b and c, If No go on to, and item with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. Your next stage is going to be easy - fill out every one of the blanks in b Write the following information, NAME First name middle initial, ADDRESS, TELEPHONE NUMBER INCLUDE AREA CODE, c Briefly explain the, Are you the natural or adoptive, Have any children in item ever, Yes, Yes, Name of Child, Date of Adoption, Name of Person Adopting, Are all the children in item now, and Yes to complete this part.

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ssa 4 conclusion process clarified (part 4)

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