Form SSA-5-BK Application for Mother's or Father's Insurance Benefits

Form SSA-5-BK Instructions

Follow these steps to complete Form SSA-5-BK:

1. Enter the full name, gender, and social security number of the deceased wage-earner. Write down your full name, social security number, date, and place of birth.
2. Identify the deceased's children and dependent grandchildren.
3. State whether you have ever filed for Social Security benefits, Supplemental Security Income, or Medicare insurance and whether you have been unable to work during the past 14 months due to an illness or injury.
4. If you have worked in the railroad industry for five years or more or you have Social Security credits in another country, answer "yes".
5. If the deceased's parents received support from the deceased, check the appropriate box.
6. Describe your marriage to the deceased and subsequent marriages - spouses' names, dates and places of marriages, how, when, and where they ended. Record who performed the marriages, and spouses' dates of birth and death.
7. Provide information about the deceased's marriages if they were married after the marriage to you.
8. State whether you and the deceased shared a household at the time of their death, and if one of you were away from home at the time of death, explain the reason.
9. Enter the amount of your total earnings last year and the expected amount of earnings this year and next year.
10. If you qualify or expect to qualify for any government pension or annuity, answer "yes" and check the boxes that apply.
11. Add the direct deposit payment address to receive the SSA benefits.
12. Certify the information in the application is true and correct, add your mailing address and telephone, sign and date the form.

SSA-5-BK Related Forms:

• Form SSA-5-BK-SP, Application for Mother's or Father's Insurance Benefits (Spanish), is filled out by applicants who prefer to use the Spanish version of the Form SSA-5-BK;
• Form SSA-5-INST, Reporting Responsibilities for Mother's or Father's Insurance Benefits, is a list of changes that must be reported to the SSA by phone, mail, or in-person - for instance, the surviving spouse's immigration status changes or the disabled child's condition improves;
• Form SSA-7-F6, Application for Parent's Insurance Benefits, and Form SSA-7-F6-SP (Spanish) are completed by dependent parents of deceased insured workers to apply for Social Security benefits.