The Worker's children or dependent grandchildren may be eligible for benefits based on the earnings record of the Worker.
Living Worker: the information in item 3 applies to this month or to any of the past 12 months.
Deceased Worker: the information in item 3 applies to the date of death or for any period since the Worker's death.
Payee: you may apply for a child even though you do not wish to be payee for the child's benefits.
Stepchildren: if any children in item 3 are stepchildren of the Worker, enter the date the Worker married the natural parent.
Items 14 and 15: complete items 14 and 15 only if the Worker is living.
| Question | Answer |
|---|---|
| Form Name | Form SSA-4-BK |
| Form Length | 9 pages |
| Fillable? | Yes |
| Fillable fields | 252 |
| Avg. time to fill out | 42 min |
| Edition | Rev 05-2023 |
| Issuing agency | Social Security Administration |
| Other names | SSA-4-BK, SSA 4 BK, SSA-4, SSA4, Form SSA-4-BK, Application for Social Security Benefits Child's Insurance Benefits |
| Official source | Form SSA-4-BK (Rev 05-2023), Social Security Administration |
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