SSA-721: Social Security Statement of Death By Funeral Director

Enter the Local Social Security Administration (SSA) Office Address. For SSA Use Only is not for you to fill in.

Please complete the required fields (*): 1.(a) Name of Deceased. Enter the Name of Deceased (First, Middle, Last, Suffix) in 1.(a). Enter Other Names Used (if known) in 1.(b).

Enter the Address of Deceased (No. and Street, P.O. Box, City/State, if known) in 1.(c).

Please complete the required field (*) 2. Enter the Social Security Number in 2. If SSN unknown, please contact local SSA office to report death.

Please complete the required fields (*) 3.(a) and 3.(b). Enter the Date of Death in 3.(a) and the City/State/Country of Death (where death occurred) in 3.(b).

Please complete the required field (*) 4.(a). Enter the Date of Birth in 4.(a). Enter the City/State/Country of Birth (if known) in 4.(b).

Please complete the required field (*) 5. In 5, check (X) whether the deceased was married: Yes or No.

Enter the Name of Surviving Spouse and names of any minor or disabled adult children (if known) in 6.(a).

Enter the Surviving Spouse SSN and SSN of any minor or disabled adult children (if known) in 6.(b).

In 7, enter the Address (No. and Street, P.O. Box) of Surviving Spouse and address of any minor or disabled adult children (if known), with City, State, ZIP Code and Telephone Number (if available).

Please complete the required fields (*) Name and Address of Funeral Director or Firm and Signature of Funeral Director or Authorized Representative. Enter the Name and Address of Funeral Director or Firm, and the Signature of Funeral Director or Authorized Representative.

Please complete the required fields (*) Telephone Number and Date. Enter the Telephone Number and the Date.

You declare under penalty of perjury that you have examined all the information on the form, and on any accompanying statements or forms, and it is true and correct to the best of your knowledge.

Anyone who knowingly gives a false or misleading statement about a material fact in the information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

Common mistake: Do not write in the space marked FOR SOCIAL SECURITY USE ONLY - DO NOT WRITE IN THIS SPACE.

If you think you may be eligible for survivors benefits, contact Social Security to apply.

Surviving spouses age 60 or older are typically eligible for benefits.

If you aren't receiving Social Security benefits, you can apply for benefits by telephone, by accessing the Social Security website www.socialsecurity.gov, or by going to any local Social Security office.

A death certificate is needed. Generally, the funeral director provides a statement that can be used for this purpose.

Your funeral director is helping the Social Security Administration by providing you this information about Social Security benefits: if the deceased was receiving benefits, contact Social Security to report the death.

Social Security can pay a one-time lump-sum death payment of $255 to a surviving spouse who was living with the worker at the time of death (checked October 20, 2026). If there is none, it can pay it to a surviving spouse who is eligible for benefits or a child or children eligible for benefits.

Form SSA-721 is the Statement of Death By Funeral Director of the Social Security Administration. Section 202 of the Social Security Act, as amended, allows Social Security to collect the information, which it will use to establish proof of death for the insured worker and determine benefits eligibility.