SSA-8: Application for Lump-Sum Death Payment

In Box 1, print your name: first name, middle initial, last name.

In Box 2(a), print the name of the Deceased Wage Earner or Self-Employed Person (herein referred to as the "deceased"): first name, middle initial, last name. In 2(b), enter the deceased's Social Security Number.

In Box 3, enter the date of birth of the deceased (MM/DD/YYYY).

In Box 4(a), enter the date of death (MM/DD/YYYY). In 4(b), enter the place of death (City and State).

Answer item 5 only if the deceased worked within the past 2 years. In 5(a), enter about how much the deceased earned from employment and self-employment during the year of death. In 5(b), enter about how much the deceased earned the year before death.

Answer item 6 only if the deceased died prior to age 66 and within the past 4 months. In 6(a), mark Yes or No: was the deceased unable to work because of illness, injuries or conditions at the time of death? If Yes, answer 6(b); if No, go on to item 7. In 6(b), enter the date the deceased became unable to work (MM/DD/YYYY).

In 7(a), mark Yes or No: was the deceased in the active military or naval service (including Reserve or National Guard active duty or active duty for training) after September 7, 1939 and before 1968? If Yes, answer 7(b) and 7(c); if No, go on to item 8. In 7(b), enter dates of service: From (MM/YYYY) To (MM/YYYY). In 7(c), mark Yes or No: has anyone (including the deceased) received, or does anyone expect to receive, a benefit from any other Federal agency?

In Box 8, mark Yes or No: did the deceased work in the railroad industry for 7 years or more?

In 9(a), mark Yes or No: did the deceased ever engage in work that was covered under the social security system of a country other than the United States? If Yes, answer 9(b); if No, go on to item 10. In 9(b), if Yes, list the country(ies).

In 10(a), mark Yes or No: is the deceased survived by a spouse? If Yes, enter information about the marriage at the time of death. If No, go on to item 10(b) if the deceased had prior marriages or item 11 if the deceased never married.

Enter the Spouse's Name (including Maiden Name), When (MM/DD/YYYY) and Where (Name of City and State). Enter How marriage ended, and When (MM/DD/YYYY) and Where (Name of City and State).

For Marriage performed by, mark Clergyman or public official or Other (Explain in "Remarks"). Enter the spouse's date of birth (or age) and Social Security Number (If none or unknown, please indicate).

If the deceased had a prior marriage(s) that lasted at least 10 years, enter the information. If the deceased married the same individual multiple times and the remarriage took place within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more, include the marriage.

If no prior marriages or if information is unavailable, please indicate.

In 11, list ALL the deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including stepgrandchildren) who are now or were in the past 12 months unmarried AND:

Under age 18; or age 18 to 19 and attending elementary or secondary school up to grade 12 full time; or age 18 or older with a disability that began before age 22. If none, write "None."

In Box 12, mark Yes or No: is there a surviving parent (or parents) of the deceased who was receiving support from the deceased either at the time the deceased became disabled under the Social Security law or at the time of death? If Yes, enter the name and address of the parent(s) in "Remarks".

In Box 13, mark Yes or No: have you filed for any Social Security benefits on the deceased's earnings record before?

In 15(a), mark Yes or No: were the deceased and the surviving spouse living together at the same address when the deceased died? If Yes, go on to item 16. If No, answer 15(b): if either the deceased or surviving spouse was away from home (whether or not temporarily) when the deceased died, give Who was away? (Deceased or Surviving spouse), Date last home, Reason absence began and Reason they were apart at time of death. If separated because of illness, enter nature of illness or disabling condition.

If you are the surviving spouse, and if you are under age 66, answer item 16. In 16(a), mark Yes or No: are you currently disabled and unable to work or was there a period during the last 14 months when you were disabled and unable to work? If Yes, enter in 16(b) the date you became disabled (MM/DD/YYYY).

Answer item 17 only if you are the surviving spouse. In item 17, mark Yes or No: were you married before your marriage to the deceased? If yes, enter information about your prior marriage(s) that lasted at least 10 years or ended due to death of the spouse.

Sign the form in ink: the applicant declares under penalty of perjury that all the information on this form, and on any accompanying statements or forms, is true and correct to the best of the applicant's knowledge.

Enter the date (MM/DD/YYYY), the telephone number(s) at which you may be contacted during the day (area code), and your mailing address (number and street, apt. no., P.O. box, or rural route), city and state, ZIP code, and the name of the county (if any) in which you now live.

In Remarks, you may use this space for any explanation. If you need more space, attach a separate sheet.

For direct deposit payment information, enter the financial institution, routing transit number and account number, and mark Checking or Savings, or Enroll in Direct Express.

Witnesses are required only if this application has been signed by mark (X). If signed by mark (X), two witnesses to the signing who know the applicant must sign, giving their full addresses.

You apply for the lump sum death payment for which you are eligible under Section 202(i) of the Social Security Act, as presently amended, on the named deceased's Social Security record.

Form SSA-8 is the Application for Lump-Sum Death Payment of the Social Security Administration. This may serve as an application for insurance benefits payable under the Railroad Retirement Act.

File this application within 2 years after the date of death of the wage earner or self-employed person.

Send or bring the completed form to your local Social Security office. Find your local Social Security office through SSA's website at www.socialsecurity.gov.