Form Approved 
Social Security Administration                                                                                     OMB No. 0960-0101
     CLAIM FOR AMOUNTS DUE IN THE CASE OF A DECEASED BENEFICIARY
PRINT NAME OF DECEASED                                              SOCIAL SECURITY NUMBER OF DECEASED  

                                                                    NAME OF THE WORKER 
If the deceased received benefits on another person's record, print 
name of that worker

The deceased may have been due a Social Security payment and/or a Medicare Premium refund. The Social 
Security Act provides that amounts due a deceased may be paid to the next of kin or the legal representative of 
the estate under priorities established in the law. To help us decide who should receive any payment due, 
please COMPLETE THIS ENTIRE FORM and RETURN it to us in the enclosed envelope. 
This claim for the amounts due is being made on behalf of the family or the estate of                      

_________________________  who died on ______________ day of ________________     _________________               
        (name of deceased)                                                 (month)                           (year)

and who lived in the state of _________________________ . 
PRINT NAME OF APPLICANT                                             RELATIONSHIP TO DECEASED (Widow, Son, Legal 
                                                                    Representative, etc.)

THE FOLLOWING ARE THE NEXT OF KIN OR LEGAL REPRESENTATIVE OF THE  DECEASED  NAMED ABOVE:
1. NAME OF SURVIVING WIDOW(ER)                                      ADDRESS OF SURVIVING WIDOW(ER)   (Please print house number, 
   (Please print.  If none, state "NONE")                           street, apt. number, P.O. Box, rural route, city, state, and ZIP code)

   ENTER SOCIAL SECURITY NUMBER(S) OF WIDOW(ER)  
   NAMED ABOVE.  

   WAS THE WIDOW(ER) NAMED ABOVE LIVING IN THE                      YES                  If "YES",  then             NO
   SAME HOUSEHOLD WITH THE DECEASED AT THE TIME                                          SKIP items  2,3,4,5 and  
   OF DEATH?                                                                             SIGN at bottom of page 2.

   WAS HE OR SHE ENTITLED TO A MONTHLY BENEFIT                      YES                  If "YES", then              NO
   ON THE SAME EARNINGS RECORD AS THE DECEASED                                           SKIP items  2,3,4,5 and      (Go on to item 2)
   AT THE TIME OF DEATH?                                                                 SIGN at bottom of page 2.
2. ENTER NUMBER OF LIVING CHILDREN OF THE DECEASED. INCLUDE ADOPTED CHILDREN AND                                     NUMBER
   STEPCHILDREN; INCLUDE GRANDCHILDREN AND STEP-GRANDCHILDREN IF THEIR PARENTS ARE 
   DISABLED OR DECEASED; OR IF THEY HAVE BEEN ADOPTED BY THE SURVIVING SPOUSE OF THE 
   DECEASED.  IF NONE OF THE ABOVE, SHOW "NONE" AND GO ON TO ITEM 4.
                                          PRINT NAME AND COMPLETE ADDRESS OF EACH CHILD 
                   Remarks -(If you need more space for explaining any answers to the questions, attach a separate sheet.) 
   NAME OF CHILD                                                    ADDRESS OF CHILD (Include house number, street, apt. number,  
                                                                    P.O. Box, rural route, city, state, and ZIP code)

   RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)           SOCIAL SECURITY NUMBER OF CHILD 

   NAME OF CHILD                                                    ADDRESS OF CHILD (Include house number, street, apt. number,  
                                                                    P.O. Box, rural route, city, state, and ZIP code)

     RELATIONSHIP TO DECEASED (Grandchild, stepchild, etc.)         SOCIAL SECURITY NUMBER OF CHILD 

Form SSA-1724-F4 (05-2016) Use Prior Editions                       Page 1

3. If any child listed in item 2 has a different name from that given at birth, attach a separate sheet with the following information:  
   Child's Present Name, Name Given At Birth, and a brief explanation for the difference (e.g. Marriage or Court Order).

4.   ENTER NUMBER OF LIVING PARENTS OF THE DECEASED                                                                     NUMBER
     (Include adopting parents and stepparents. If none, show "None") IF THERE ARE NO LIVING PARENTS, GO 
     ON TO ITEM 5. 
                            PRINT NAME AND COMPLETE ADDRESS OF EACH PARENT
     NAME OF LIVING PARENT                                    ADDRESS OF LIVING PARENT (Include house number, street, apt. 
                                                              number, P.O. Box, rural route, city, state, and ZIP code)

     ENTER SOCIAL SECURITY NUMBER OF PARENT  NAMED  

     NAME OF LIVING PARENT                                    ADDRESS OF LIVING PARENT (Include house number, street, apt. 
                                                              number, P.O. Box, rural route, city, state, and ZIP code)

     ENTER SOCIAL SECURITY NUMBER OF PARENT NAMED.  

5.   LEGAL REPRESENTATIVE OF THE DECEASED'S ESTATE (Skip this item if relatives are listed in 1, 2, or 4.)
     NAME OF LEGAL REPRESENTATIVE (Please print)              ADDRESS OF LEGAL REPRESENTATIVE (Please print house 
                                                              number, street, apt. number, P.O. Box, rural route, city, state, and 
                                                              ZIP code.)

     NOTE:  If you are applying as legal representative, please submit a certified copy of your letters of appointment.

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
SIGNATURE (First name, middle initial, last name) DATE (Month, day, year)          TELEPHONE NUMBER   
                                                                                   (Include area code) 

MAILING ADDRESS (House number and street, apt. number, P.O. Box, or rural route)

CITY                        STATE                                   NAME OF COUNTY      ZIP CODE

                            Direct Deposit Payment Address (Financial Institution)
                     Type of Account                                            Nine Digit Routing Number

                   Checking Savings

Account Number

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. 
SIGNATURE OF WITNESS                                                SIGNATURE OF WITNESS

ADDRESS (House number and street, city, state, and ZIP code)        ADDRESS (House number and street, city, state, and ZIP code)

Form SSA-1724-F4 (05-2016)                                   Page 2

                                                                                                       PRIVACY ACT NOTICE
Section 204(d) of the Social Security Act, as amended, authorizes us to collect this information. We will use this 
information to help us determine the beneficiary’s payment. 
  
Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested information 
may prevent us from making an accurate and timely decision on your claim, which may result in the loss of payments. 
  
We rarely use the information you supply for any purpose other than for determining problems in Social Security 
programs. However, we may use it for the administration and integrity of Social Security programs. We may also 
disclose information to another person or to another agency in accordance with approved routine uses, which include, 
but are not limited to the following:
  1)         To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security 
     Administration in the efficient administration of its programs; 
  2)         To comply with Federal laws requiring the release of information from Social Security records (e.g., to the 
     Government Accountability Office and Department of Veteran's Affairs); 
  3)         To make determinations for eligibility in similar health and income maintenance programs at the Federal, 
     State, and local level; and,  
  4)         To facilitate statistical research, audit, or investigatory activities necessary to assure the integrity and 
     improvement of Social Security programs.            
We may also use the information you provide in computer matching programs.  Matching programs compare our 
records with records kept by other Federal, State, or local government agencies.  We use the information from these 
matching programs to establish or verify a person's eligibility for federally-funded and administered benefit programs 
and for repayment, incorrect payments or delinquent debts under these programs.   
 
A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089, 
Claims Folder Systems, and 60-0090, Master Beneficiary Record.  These notices, additional information regarding our 
programs and systems, are available on-line at www.socialsecurity.gov or at any local Social Security office. 

                                                                 Paperwork Reduction Act StatementThis 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.

Form SSA-1724-F4 (05-2016)                                                                                         Page 3