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

Life Claim and Death Claim are in the space marked (Do not write in this space): do not write in them.

In box 1, print the name of the Wage Earner or Self-Employed person (the Worker) and print the Worker's Social Security number.

In box 2, print your name (unless you are the Worker) and print your Social Security number.

List all children who are: Under age 18; Age 18 to 19 and attending elementary or secondary school (grade 12 or lower) full-time; Age 18 or older with a disability that began before age 22.

For each child, enter the full name of child, the child's Social Security number and the Date of Birth (MM/DD/YYYY).

Check (X) if the child 17.5 or older is a Student or Disabled.

Check (X) the column that shows the child's relationship to the Worker: Natural, Adopted, Stepchild, Dependent Grandchild or Other.

If any children in item 3 are stepchildren of the Worker, enter the date the Worker married the natural parent (MM/DD/YYYY).

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

In box 5(b), write the name (First name, middle initial, last name), address and telephone number (include area code) of the legal representative(s). In 5(c), briefly explain the circumstances which led the court to appoint a legal representative.

In box 6, mark Yes or No: are you the natural or adoptive parent of the person(s) for whom you are filing?

In item 7, mark Yes or No: have any children in item 3 ever been adopted by someone other than the Worker? If "Yes," enter the Name of Child, Date of Adoption and Name of Person Adopting.

In item 8, mark Yes or No: are all the children in item 3 now living in the same household with you? If "No," for each child not living with you, enter the Name of Child Not Living With You, the Person With Whom Child Now Lives (Name and Address) and Relationship to Child. If uncertain as to the whereabouts of any of these children, explain in "Remarks".

In item 9, mark Yes or No: has any child in item 3 ever been married? If "Yes," enter the information requested in box 9. How Marriage Ended (If still married, write "not ended").

If you are applying ONLY for a child age 18 or over who is disabled, omit items 10 through 13. In all other cases, answer items 10 through 13.

In item 10, mark Yes or No: did any child in item 3 earn more than the exempt amount last year? Do not complete item 10 if the Worker died this year. If "Yes," answer (b). If "No," go on to item 11.

In item 11, mark Yes or No: 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 first of this year and all anticipated earnings through the end of this year.) If "Yes," answer (b). If "No," go on to item 12.

Complete item 12 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). In item 12, mark Yes or No: 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 13.

Complete items 14 and 15 ONLY if the Worker is living. Otherwise, go on to item 16. In item 14, 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.

In item 15, mark Yes or No: 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 in box 15.

Sign as applicant and enter the Date (MM/DD/YYYY). Under "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."

Enter the telephone number(s) at which you may be contacted during the day.

Witnesses are required ONLY if this application has been signed by mark (X) in the signature box. If signed by mark (X), two witnesses to the signing who know the applicant must sign in the witness boxes giving their full addresses. Also, print the applicant's name in the signature block.

For Direct Deposit Payment Information (Financial Institution), enter the Routing Transit Number and Account Number and check Checking or Savings, or check Enroll in Direct Express or Direct Deposit Refused.

Enter the 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 and County (if any) in which you now live.

Form SSA-4-BK, Application for Social Security Benefits: Child's Insurance Benefits, is how you apply on behalf of the child or children listed in item 3. Use of the personal information collected: to determine eligibility for monthly benefits or insurance coverage and to authorize payments to the child(ren) of retired, disabled, or deceased workers.

Send or bring the completed form to your local Social Security office.