Form Ssa 4 Bk – Fill Out and Use This PDF

Form SSA 4 Bk is a vital document you will have to complete in order to file for most Social Security benefits. It's the form that beings the process and pulls together important information such as your identity, income and contacts. Without Form SSA 4 Bk, you won't be able to proceed with filing for Social Security benefits, so it pays to remember what this form is. Depending on your particular filter of Social Security benefits, certain parts of this form may or may not be applicable depending everything from living arrangements to family savings. However, once all of the proper information is filled out accurately, the form will become an integral part of obtaining what it is you are seeking from Social Security.

Form Ssa 4 Bk PDF Details

The Social Security Administration (SSA) Form SSA-4-Bk, also known as the Registration of a Representative Payee for an Individual with a Mental Impairment, is used to identify and appoint a representative payee for an individual who has a mental impairment. The form must be completed by both the representative payee and the individual who has the mental impairment. The purpose of the form is to help ensure that the individual's needs are met in a timely and appropriate manner. Completed forms should be sent to the local SSA office.

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

Form Preview Example

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.)

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

Page 6 of 9

Con'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.

SIGNATURE OF APPLICANT	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

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)

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)

Form SSA-4-BK (01-2017) UF	Page 7 of 9

Privacy Act Statement

Collection and Use of Personal Information

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 (MDB) File. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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 (OMB) 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 of 9

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY CHILD'S INSURANCE BENEFITS

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

OR SOMETHING TO REPORT

BEFORE YOU RECEIVE A NOTICE OF AWARD

AFTER YOU RECEIVE A NOTICE OF AWARD

SSA OFFICE

DATE CLAIM RECEIVED

Your application 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.

You should hear from us within days after you have given us all the information we requested. Some claims may take longer if additional information is needed.

In the meantime, if you or any child(ren) changes address, or if there is some other change that may affect your claim, you or someone for you should report the change. The changes to be reported are listed below.

Always give us your claim number when writing or telephoning about your claim.

If you have any questions about your claim, we will be glad to help you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

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

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 residence. To avoid delay in receipt of checks you should ALSO file a regular change of address notice with your post office.

•Any child's citizenship or immigration status changes.

•Any beneficiary goes outside the U.S.A. for 30 consecutive days or longer.

•Any beneficiary dies or becomes unable to handle benefits.

•Work changes - On your application you told us

expected total earnings

(Name of Child)

for		to be $		.
	(Year)
			(is)		(is not) earning
	(Name of Child)
wages of more than $					a month.

•A student, age 18 or over, stops attending school, reduces school attendance below full-time, changes schools, or is paid by an employer to attend school.

•If the worker and stepchild's parent divorce. Benefits are not payable to a stepchild beginning with the month after the month the worker and the stepchild's parent divorce. Promptly return any benefit payment received on behalf of the stepchild for the months after the month the divorce becomes final.

•The child is confined for more than 30 continuous days to a jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by a court order in connection with a crime.

•Change in Marital Status - Marriage, divorce, or annulment of marriage. You must report marriage even if you believe that an exception applies.

•Disability Applicants - In addition to the applicable

(is) (is not) self-employed

(Name of Child)

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.

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

•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 flight- escape.

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:

•Visiting the section "What You Can Do Online" 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, visiting or writing your local Social Security office at the phone number and address above.

For general information about Social Security, visit our web site at www.socialsecurity.gov.

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 responsibility to ensure that the information you give concerning the child's earnings is correct.

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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.

4. This next section requires some additional information. Ensure you complete all the necessary fields - With You, Name and Address, Relationship to Child, Has any child in item ever been, Yes, Name of Child, Date of Marriage Month day year, How Marriage Ended If still, Date Marriage Ended Month day year, Has anyone ever before filed an, Administration for monthly, Name of Worker, Yes, and Social Security Number of Worker - to proceed further in your process!

ssa 4 conclusion process clarified (part 4)

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