Form Death Payment Details

Form SSA 8 is a new form that was created by the Social Security Administration in an effort to streamline the disability application process. The form is designed to collect key information about an applicant's medical history and work history, and it can be used to apply for both Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Anyone who is considering applying for disability benefits should review the instructions for Form SSA 8 carefully and complete the form as accurately as possible. By providing all of the required information, you can help ensure that your application is processed quickly and efficiently.

This table provides details about form ssa 8. There, you will discover the information regarding the document you intend to fill out, along with the approximate time for you to complete it and also other details.

QuestionAnswer
Form NameForm Ssa 8
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesssa forms ssa 8, social security form ssa 8, ssa 8 form, where to send form ssa 8

Form Preview Example

Form SSA-8 (01-2020) UF

 

Discontinue Prior Editions

OMB No. 0960-0013

Social Security Administration

Page 1 of 4

APPLICATION FOR LUMP-SUM DEATH PAYMENT*

I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) of the Social Security Act, as presently amended, on the named deceased's Social Security record.

(This application must be filed within 2 years after the date of death of the wage earner or self-employed person.)

*This may also be considered an application for insurance benefits payable under the Railroad Retirement Act.

1.

(a) PRINT name of Deceased Wage Earner

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

or Self-Employed Person (herein referred

 

 

 

 

 

to as the "deceased")

 

 

 

 

 

 

(b) Check (X) one for the deceased

 

Male

Female

 

 

 

 

 

 

 

 

 

(c) Enter deceased's Social Security Number

 

 

 

 

 

 

 

 

 

 

2.

PRINT your name

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Enter date of birth of deceased

 

 

 

 

 

 

(Month, day, year)

 

 

 

 

 

 

 

 

 

 

 

 

4.

(a) Enter date of death

 

 

 

 

 

 

(Month, day, year)

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Enter place of death

 

 

 

 

 

 

(City and State)

 

 

 

 

 

 

 

 

 

 

 

5.

(a) Did the deceased ever file an application for Social

Yes

No

Unknown

 

Security benefits, a period of disability under

 

 

 

 

Social Security, Supplemental Security Income, or

(If "Yes," answer

(If "No" or "Unknown," go on to

 

hospital or medical insurance under Medicare?

(b) and (c).)

item 6.)

 

 

(b) Enter name(s) of person(s) on whose Social

FIRST NAME, MIDDLE INITIAL, LAST NAME

 

Security record(s) other application was filed.

 

 

 

 

 

 

 

 

 

 

 

(c)Enter Social Security Number(s) of person(s) named in

(b). (If unknown, so indicate)

6.ANSWER ITEM 6 ONLY IF THE DECEASED WORKED WITHIN THE PAST 2 YEARS.

(a)About how much did the deceased earn from employment AMOUNT

and self-employment during the year of death?

$

 

 

(b) About how much did the deceased earn the year

AMOUNT

before death?

$

7.ANSWER ITEM 7 ONLY IF THE DECEASED DIED PRIOR TO AGE 66 AND WITHIN THE PAST 4 MONTHS

 

(a) Was the deceased unable to work because of

Yes

No

 

(If "Yes," answer

(If "No," go on to item 8.)

 

illness, injuries or conditions at the time of death?

 

(b).)

 

 

 

 

 

 

 

 

 

(b) Enter the date the deceased became unable to work

 

 

 

(Month, day, year)

 

 

8. (a) Was the deceased in the active military or naval

Yes

No

 

service (including Reserve or National Guard active

 

 

 

duty or active duty for training) after September 7,

(If "Yes," answer

(If "No," go on to item 9.)

 

1939 and before 1968?

(b) and (c).)

 

 

 

 

 

 

(b) Enter dates of service.

From: (Month, Year)

To: (Month, Year)

 

 

 

 

 

 

 

 

(c) Has anyone (including the deceased) received, or

 

 

 

does anyone expect to receive, a benefit from any

Yes

No

 

other Federal agency?

 

 

9.Did the deceased work in the railroad industry for

7 years or more?

 

Yes

 

No

 

 

 

 

Form SSA-8 (01-2020) UF

 

Page 2 of 4

 

 

 

 

10. (a) Did the deceased ever engage in work that was covered under the social

Yes

(If "Yes," answer (b).)

 

security system of a country other than the United States?

No

(If "No," go on to item 11.)

 

 

 

 

 

 

(b)If "Yes," list the country(ies).

11.(a) Is the deceased survived by a spouse?

If "Yes," enter information about the marriage at the time of death below. If "No," go on to

Yes

No

item 11(b) if the deceased had prior marriages or item 12 if the deceased never married.

 

 

Spouse's Name (including Maiden Name)

When (Month, day, year)

Where (Name of City and State)

 

 

 

 

 

How marriage ended

When (Month, day, year)

Where (Name of City and State)

 

 

 

 

 

 

Marriage performed by:

Spouse's date of birth (or age)

Spouse's Social Security Number (If

Clergyman or public official

none or unknown, so indicate)

 

Other (Explain in "Remarks")

 

 

 

 

(b)If the deceased had a prior marriage(s) that lasted at least 10 years, enter the information below. 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 below.

Spouse's Name (including Maiden Name)

When (Month, day, year)

Where (Name of City and State)

 

 

 

How marriage ended

When (Month, day, year)

Where (Name of City and State)

 

 

 

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date

 

Clergyman or public official

of death

Other (Explain in "Remarks")

 

 

Spouse's Social Security Number (If none or unknown, so indicate)

(c)If the deceased has a surviving child(ren) as defined in item 12 and the deceased was married to the child's mother or father but the marriage ended in divorce, enter information on the marriage if not already listed in 11(b). If no prior marriages or if information is unavailable, please indicate below.

Spouse's Name (including Maiden Name)

When (Month, day, year)

Where (Name of City and State)

 

 

 

How marriage ended

When (Month, day, year)

Where (Name of City and State)

 

 

 

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date

 

Clergyman or public official

of death

Other (Explain in "Remarks")

 

 

Spouse's Social Security Number (If none or unknown, so indicate)

12.The deceased's surviving children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on the earnings record of the deceased.

List below ALL such children who are now or were in the past 12 months UNMARRIED and:

UNDER AGE 18 • AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL

AGE 18 OR OLDER WITH A DISABILITY THAT BEGAN BEFORE AGE 22

(If none, write ''None.'')

Full Name of Child

Full Name of Child

 

 

 

 

 

 

 

 

 

 

13.

Is there a surviving parent (or parents) of the deceased who

Yes

No

 

was receiving support from the deceased either at the time

 

(If "Yes," enter the name and

 

 

the deceased became disabled under the Social Security law

 

 

or at the time of death?

address of the parent(s) in "Remarks".)

14.

Have you filed for any Social Security benefits on the

Yes

No

 

deceased's earnings record before?

 

 

 

NOTE: If there is a surviving spouse, continue with item 15. If not, skip items 15 through 18.

15.If you are not the surviving spouse, enter the surviving spouse's name and address here

Form SSA-8 (01-2020) UF

 

Page 3 of 4

 

 

 

 

16. (a) Were the deceased and the surviving spouse living

Yes

No

 

together at the same address when the deceased died?

(If "Yes," go on to item 17.)

(If "No," answer (b).)

(b)If either the deceased or surviving spouse was away from home (whether or not temporarily) when the deceased died, give the following:

 

Who was away?

 

Deceased

 

Surviving spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date last home

Reason absence began

 

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 17.

 

 

 

 

 

 

 

 

 

 

 

17.

(a) Are you so disabled that you cannot work or was there some period during the last 14

 

Yes

No

 

months when you were so disabled that you could not work?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) If ''Yes,'' enter the date you became disabled.

 

 

 

(Month, day, year)

 

 

 

 

 

 

 

 

 

Answer 18 ONLY if you are the surviving spouse.

 

 

 

 

 

 

18.

Were you married before your marriage to the deceased? If yes, enter information about your

 

Yes

No

 

prior marriage(s) that lasted at least 10 years or ended due to death of the spouse. If you

 

 

divorced then remarried the same individual within the year immediately following the year of

 

 

 

 

the divorce and the combined period of marriage totaled at least 10 years, include the marriage.

 

 

 

If you need more space, use "Remarks" section on back page or attach a separate sheet.

 

 

 

 

Spouse's Name (including Maiden Name)

When (Month, day, year)

Where (Name of City and State)

 

 

 

 

 

 

 

 

How marriage ended

 

When (Month, day, year)

Where (Name of City and State)

 

 

 

 

 

 

 

 

 

 

 

 

Marriage performed by:

 

Spouse's date of birth (or age)

If spouse deceased, give date

 

 

 

 

 

 

 

Clergyman or public official

of death

 

 

 

 

Other (Explain in "Remarks")

 

 

 

 

 

 

 

 

Spouse's Social Security Number (If none or unknown, so indicate)

 

 

 

 

 

 

 

 

 

 

 

For additional information about survivor benefits see our publication at www.socialsecurity.gov.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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.

SIGNATURE OF APPLICANT

Date (Month, day, year)

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number(s) at Which You

May Be Contacted During the Day

(Area Code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code Enter Name of County (if any) in which you now live

Direct Deposit Payment Information (Financial Institution)

Routing Transit Number

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

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.

1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State, and ZIP Code)

Address (Number and street, City, State, and ZIP Code)

Form SSA-8 (01-2020) UF

Page 4 of 4

 

 

RECEIPT FOR YOUR CLAIM FOR THE SOCIAL SECURITY LUMP-SUM DEATH PAYMENT

TELEPHONE NUMBER TO CALL IF YOU HAVE A QUESTION OR SOMETHING TO REPORT

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER

RECEIPT FOR YOUR CLAIM

Your application for the lump-sum death payment has been received and will be processed as quickly as possible.

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 change your mailing address, you should report the change.

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

DECEASED'S NAME (If surname differs from claimant's name)

Privacy Act Statement - Application for Lump-Sum Death Payment

Collection and Use of Personal Information

Section 202 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely determination on any claim filed and could result in a loss of a Social Security Administration (SSA) provided benefit.

We will use the information to authorize our one-time disbursement of the lump-sum death payment to a widow, widower, or children as defined in Section 202. We may also share your information for the following purposes, called routine uses:

Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose of assisting the 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; and

To a congressional office in response to an inquiry from that office made at the request of the subject of a record.

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 Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 10 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.

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