This form contains 276 fields organized into 69 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Information
REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.)	Text	Use this space to provide any additional explanations or remarks. Attach a separate sheet if more space is needed.
Con't Remarks	Text	Continue any remarks or explanations from the previous section if more space is needed.
DecimalField1	Number	Provide any relevant decimal value related to the child's application. Please refer to the form instructions for specific details.
Additional Resources
SSALink	Button	This button likely provides a link to additional resources or information related to the Social Security Administration. Click it to access further details or assistance.
Administrative Details
SSA OFFICE	Text	Enter the name or location of the Social Security Administration office handling your application. This information helps in tracking and managing your application process.
Adoption Information
7 Have any children in item 3 ever been adopted by someone other than the Worker? (If "Yes," enter the following information in the table): Yes	CheckBox	Select 'Yes' if any of the children listed in item 3 have been adopted by someone other than the worker. Provide additional details in the table if applicable.
No	CheckBox	Select 'No' if none of the children listed in item 3 have been adopted by someone other than the worker.
This is a Table with 3 columns and 2 rows. Column headers are Name of Child, Date of Adoption, and Name of Person Adopting. Name of Child 1	Text	Enter the name of the first child who has been adopted by someone other than the worker.
Date of Adoption of Child 1	Date	Provide the date when the first child was adopted by someone other than the worker.
Name of Person Adopting Child 1	Text	Enter the name of the person who adopted the first child.
Name of Child 2	Text	Enter the name of the second child who has been adopted by someone other than the worker.
Date of Adoption of Child 2	Date	Provide the date when the second child was adopted by someone other than the worker.
Name of Person Adopting Child 2	Text	Enter the name of the person who adopted the second child.
Complete items 15 and 16 ONLY if the Worker is living. Otherwise, go on to item 17. 15. If any children in item 3 are children adopted by the Worker, print below the name of each such child and the date of adoption by the Worker. This is a table with 2 columns and 4 rows, Column headers are Name of Adopted Child and Date of Adoption. Name of first adopted child	Text	If the worker is living, enter the name of the first adopted child and the date they were adopted by the worker.
Date of first child's Adoption	Date	Enter the date of adoption for the first adopted child by the worker.
Name of second adopted child	Text	If applicable, enter the name of the second adopted child by the worker.
Date of second child's Adoption	Date	Enter the date of adoption for the second adopted child by the worker.
Name of third adopted child	Text	If applicable, enter the name of the third adopted child by the worker.
Date of third child's Adoption	Date	Enter the date of adoption for the third adopted child by the worker.
Name of fourth adopted child	Text	If applicable, enter the name of the fourth adopted child by the worker.
Date of fourth child's Adoption	Date	Enter the date of adoption for the fourth adopted child by the worker.
Applicant Information
FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter the first name, middle initial, and last name of the applicant.
(b) PRINT your Social Security number	Text	Enter your Social Security number.
Application Details
DATE CLAIM RECEIVED	Date	Enter the date on which the claim for child's insurance benefits was received by the Social Security Administration. This date is important for processing and tracking the application.
Application Status
Your application for Social Security benefits on behalf of the child(ren) named below has been received. You will be notified by mail as soon as a decision is made on your claim. You should hear from us within blank line days after you have given us all the information we requested. Enter information for blank line	Text	Enter the number of days you expect to wait after submitting all requested information before receiving a decision on the child's Social Security benefits claim.
Bank Information
Account Number	Text	Enter the bank account number where the child's insurance benefits should be deposited.
Checking	CheckBox	Check this box if the bank account is a checking account.
Savings	CheckBox	Check this box if the bank account is a savings account.
Banking Information
Routing Transit Number	Text	Enter the routing transit number for banking purposes.
Child 1 Information
Child 1 is Female	CheckBox	Indicate if Child 1 is female by checking this box.
Date of Birth (Month, day, year) for Child 1	Date	Enter the date of birth for Child 1 in the format Month, Day, Year.
Child's Social Security Number for Child 1	Text	Enter the Social Security Number for Child 1.
Child 1 Relationship to Worker
Child one's Relationship to Worker is Legitimate	CheckBox	Check this box if Child 1's relationship to the worker is legitimate.
Child one's Relationship to Worker is Adopted	CheckBox	Check this box if Child 1's relationship to the worker is adopted.
Child one's Relationship to Worker is Stepchild	CheckBox	Check this box if Child 1's relationship to the worker is as a stepchild.
Child one's Relationship to Worker is Dependent Grandchild	CheckBox	Check this box if Child 1's relationship to the worker is as a dependent grandchild.
Child one's Relationship to Worker is other	CheckBox	Check this box if Child 1's relationship to the worker is other than the specified options.
Child 1 Status
Child one, 17.5 or Older is Student	CheckBox	Check this box if Child 1 is 17.5 years or older and is a student.
Child 1, 17.5 or Older is Disabled	CheckBox	Check this box if Child 1 is 17.5 years or older and is disabled.
Child 2 Identification
Child's Social Security Number for Child 2	Text	Enter the Social Security Number of Child 2.
Child 2 Information
Full Name of Child 2 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Enter the full name of Child 2. Specify if they are under age 18, age 18 to 19 and attending school full-time, or disabled/handicapped with disability beginning before age 22.
Child 2 is Male	CheckBox	Indicate if Child 2 is male by checking this box.
Child 2 is Female	CheckBox	Indicate if Child 2 is female by checking this box.
Date of Birth (Month, day, year) for Child 2	Date	Enter the date of birth for Child 2 in the format Month, Day, Year.
Child 2 Relationship
Child two's Relationship to Worker is Legitimate	CheckBox	Check this box if Child 2's relationship to the worker is legitimate.
Child two's Relationship to Worker is Adopted	CheckBox	Check this box if Child 2's relationship to the worker is through adoption.
Child two's Relationship to Worker is Stepchild	CheckBox	Check this box if Child 2 is a stepchild of the worker.
Child two's Relationship to Worker is Dependent Grandchild	CheckBox	Check this box if Child 2 is a dependent grandchild of the worker.
Child two's Relationship to Worker is other	CheckBox	Check this box if Child 2's relationship to the worker is other than the specified options.
Child 2 Status
Child 2, 17.5 or Older is Student	CheckBox	Check this box if Child 2 is 17.5 years or older and is a student.
Child 2, 17.5 or Older is Disabled	CheckBox	Indicate if Child 2, who is 17.5 years or older, is disabled.
Child 3 Gender
Child 3 is Male	CheckBox	Check this box if Child 3 is male.
Child 3 is Female	CheckBox	Check this box if Child 3 is female.
Child 3 Identification
Full Name of Child 3 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Enter the full name of Child 3, who is under age 18, or age 18 to 19 and attending school full-time, or disabled/handicapped with disability beginning before age 22.
Date of Birth (Month, day, year) for Child 3	Date	Enter the date of birth for Child 3 in the format Month, Day, Year.
Child 3 Relationship
Child three's Relationship to Worker is Legitimate	CheckBox	Check this box if Child 3's relationship to the worker is legitimate.
Child three's Relationship to Worker is Adopted	CheckBox	Check this box if Child 3's relationship to the worker is through adoption.
Child 3 Status
Child 3, 17.5 or Older is Student	CheckBox	Indicate if Child 3, who is 17.5 years or older, is a student.
Child 3, 17.5 or Older is Disabled	CheckBox	Indicate if Child 3, who is 17.5 years or older, is disabled.
Child Demographics
Child 4 is Male	CheckBox	Indicate the gender of Child 4. Check this box if the child is male.
Child 4 is Female	CheckBox	Indicate the gender of Child 4. Check this box if the child is female.
Date of Birth (Month, day, year) for Child 4	Date	Enter the date of birth for Child 4 in the format of month, day, and year.
Child Earnings Information
TOTAL EARNINGS OF third CHILD	Number	Enter the total earnings for the third child for the current year. This includes all income from wages and self-employment.
LIST EACH MONTH THAT third CHILD DID NOT EARN MORE THAN $ Amount entered into the blank line in Number 11 IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month in which the third child did not earn more than the specified amount in wages and did not perform substantial services in self-employment.
Name of first CHILD who expects to earn over the exempt amount this year	Text	Enter the name of the first child who expects to earn over the exempt amount this year.
EXPECTED EARNINGS OF first CHILD	Number	Enter the expected earnings for the first child for the current year.
List each month (including the present month) that first CHILD did not or will not earn more than the amount entered into the blank line in Number 12 in wages and did not or will not perform substantial services in self-employment	Text	List each month, including the present month, that the first child did not or will not earn more than the specified amount in wages and did not or will not perform substantial services in self-employment.
Name of second CHILD who expects to earn over the exempt amount this year	Text	Enter the name of the second child who expects to earn over the exempt amount this year.
EXPECTED EARNINGS OF second CHILD	Number	Enter the expected earnings for the second child for the current year.
List each month (including the present month) that second CHILD did not or will not earn more than the amount entered into the blank line in Number 12 in wages and did not or will not perform substantial services in self-employment	Text	List each month, including the present month, that the second child did not or will not earn more than the specified amount in wages and did not or will not perform substantial services in self-employment.
Name of third CHILD who expects to earn over the exempt amount this year	Text	Enter the name of the third child who expects to earn over the exempt amount this year.
EXPECTED EARNINGS OF third CHILD	Number	Enter the expected earnings for the third child for the current year. This should include all forms of income the child anticipates receiving.
List each month (including the present month) that third CHILD did not or will not earn more than the amount entered into the blank line in Number 12 in wages and did not or will not perform substantial services in self-employment	Text	List each month where the third child did not or will not earn more than the specified amount in wages and did not or will not perform substantial services in self-employment.
Complete item 13 ONLY if any child is now in the last 4 months of the child's taxable year (September, October, November, and December, if the taxable year is a calendar year). EARNINGS INFORMATION FOR NEXT YEAR 13. ( ay) Do you expect the total earnings of any child in item 3 to be more than the exempt amount next year? (If "Yes," answer (b.) Yes	CheckBox	Indicate if you expect the total earnings of any child listed in item 3 to exceed the exempt amount next year. Check 'Yes' if applicable.
(If "No," go on to item 14.) No	CheckBox	Indicate if you do not expect the total earnings of any child listed in item 3 to exceed the exempt amount next year. Check 'No' if applicable.
13(b) This is a table with 3 columns and 3 rows. Column headers are Name of child who expects to earn over the exempt amount next year, Expected Earnings of child, and List each month that child will not earn more than $ blank line in wages and will not perform substantial services in self-employment. Enter amount for blank line	Number	Enter the amount for the blank line in the table, which represents the threshold for earnings and substantial services in self-employment for the child.
NAME OF first CHILD WHO EXPECTS TO EARN OVER THE EXEMPT AMOUNT NEXT YEAR	Text	Enter the name of the first child who expects to earn over the exempt amount next year.
EXPECTED EARNINGS OF first CHILD	Number	Enter the expected earnings for the first child for the next year. This should include all forms of income the child anticipates receiving.
LIST EACH MONTH THAT first CHILD WILL NOT EARN MORE THAN the amount entered into the blank line in Number 13 IN WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month where the first child will not earn more than the specified amount in wages and will not perform substantial services in self-employment.
NAME OF second CHILD WHO expects to earn over the exempt amount next year	Text	Enter the name of the second child who expects to earn over the exempt amount next year.
EXPECTED EARNINGS OF second CHILD	Number	Enter the expected earnings for the second child for the next year. This should include all forms of income the child anticipates receiving.
LIST EACH MONTH THAT second CHILD WILL NOT EARN MORE THAN the amount entered into the blank line in Number 13 IN WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month where the second child will not earn more than the specified amount in wages and will not perform substantial services in self-employment.
NAME OF third CHILD WHO expects to earn over the exempt amount next year	Text	Enter the name of the third child who expects to earn over the exempt amount next year.
EXPECTED EARNINGS OF third CHILD	Number	Enter the expected earnings for the third child for the current year. This should include all sources of income.
LIST EACH MONTH THAT third CHILD WILL NOT EARN MORE THAN the amount entered into the blank line in Number 13 IN WAGES AND WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month during which the third child will not earn more than the specified amount in wages and will not perform substantial services in self-employment.
Name of child and month fiscal year ends	Text	Provide the name of the child and the month in which the fiscal year ends for their earnings.
Child Gender
Child 5 is Male	CheckBox	Check this box if Child 5 is male.
Child 5 is Female	CheckBox	Check this box if Child 5 is female.
Child 6 is Male	CheckBox	Check this box if Child 6 is male.
Child Identification
Child's Social Security Number for Child 3	Text	Enter the Social Security Number of Child 3. This is a nine-digit number unique to the child.
Full Name of Child 4 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Provide the full name of Child 4. Include first, middle, and last names as applicable.
Child's Social Security Number for Child 4	Text	Enter the Social Security Number for Child 4. This is a unique nine-digit number assigned to the child by the Social Security Administration.
Full Name of Child 5 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Provide the full name of Child 5. Indicate if the child is under age 18, between 18 to 19 and attending school full-time, or disabled/handicapped with a disability that began before age 22.
Date of Birth (Month, day, year) for Child 5	Date	Enter the date of birth for Child 5 in the format of month, day, and year.
Child's Social Security Number for Child 5	Text	Enter the Social Security Number for Child 5. This is a unique nine-digit number assigned to the child by the Social Security Administration.
Full Name of Child 6 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Provide the full name of Child 6. Indicate if the child is under age 18, between 18 to 19 and attending school full-time, or disabled/handicapped with a disability that began before age 22.
Child Information
Part 1 - Information about the worker's children 3. The Worker's children (including natural children, adopted children, and stepchildren) or dependent grandchildren (including step grandchildren) may be eligible for benefits based on the earnings record of the Worker. For a living Worker, the information below applies to this month or to any of the past 12 months. For a deceased Worker, the information below applies to the date of death or for any period since the Worker's death. Below is a table with 6 rows and 12 columns. Column headers are List below all children who are • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22) Full Name of child; Check (X) Sex of Child M; Check (X) Sex of Child F, Date of Birth (Month, Day, Year); Check (X) if child 17 or older is: Student; Check (X) if Child 17 or Older is: Disabled; Check (X) the Column That Shows Child's Relationship to Worker Legitimate; Check (X) the Column That Shows Child's Relationship to Worker Adopted; Check (X) the Column That Shows Child's Relationship to Worker Stepchild; Check (X) the Column That Shows Child's Relationship to Worker Dependent Grandchild; Check (X) the Column That Shows Child's Relationship to Worker Other; and Child's Social Security Number. Full Name of Child 1 • Under age 18 • Age 18 to 19 and attending elementary or secondary school full-time • Disabled or Handicapped (age 18 or over and disability began before age 22)	Text	Provide information about the worker's children or dependent grandchildren who may be eligible for benefits. Include full name, age, school attendance, disability status, relationship to the worker, and Social Security number.
Child 1 is Male	CheckBox	Check this box if Child 1 is male.
Child 6 is Female	CheckBox	Check this box if Child 6 is female.
Date of Birth (Month, day, year) for Child 6	Date	Enter the date of birth for Child 6 in the format Month, Day, Year.
Child's Social Security Number for Child 6. If you do not wish to be payee for any child or dependent grandchild named above, list the child's name and address in "Remarks" on page 5. You may apply for a child even though you do not wish to be payee for the child's benefits	Text	Enter the Social Security Number for Child 6. If you do not wish to be the payee for this child, list the child's name and address in the 'Remarks' section on page 5.
Name of Child	Text	Enter the name of the child.
This is a table with 3 columns and 4 rows. Column headers are Name of Child Not Living With You, Name and Address of Person with whom child now lives, and the Relationship to Child for Person with whom child now lives. Name of Child 1 not living with you	Text	Enter the name of the first child who is not living with you.
Name of Child 2 not living with you	Text	Enter the name of the second child who is not living with you.
Name of Child 3 not living with you	Text	Enter the name of the third child who is not living with you.
Name of Child 4 not living with you	Text	Enter the name of the fourth child who is not living with you.
This is a table of 3 columns and 4 rows. Column headers are Name of Child, Name of Worker, Social Security Number of Worker. Name of Child 1	Text	Enter the name of the first child for whom a previous application for benefits was filed.
Name of Child 2	Text	Enter the name of the second child for whom a previous application for benefits was filed.
Name of Child 3	Text	Enter the name of the third child for whom a previous application for benefits was filed.
Name of Child 4	Text	Enter the name of the fourth child for whom a previous application for benefits was filed.
This is a table with 4 columns and 2 rows. Column Headers are Name of child who did not live with the worker in each of the last 13 months, List each month in which this child did not live with the worker, Name and Address for person with whom child lived, and relationship to child, for person with whom child lived. Name of first child who did not live with the worker in each of the last 13 months	Text	Enter the name of the first child who did not live with the worker during any of the last 13 months.
LIST EACH MONTH IN WHICH first CHILD DID NOT LIVE WITH THE WORKER	Text	List each month in which the first child did not live with the worker during the last 13 months.
Name and Address for the person with whom first child lived	Text	Provide the name and address of the person with whom the first child lived during the months they did not live with the worker.
Relationship to child for person with whom first child lived	Text	Specify the relationship to the child for the person with whom the first child lived.
Name of second child who did not live with the worker in each of the last 13 months	Text	Enter the name of the second child who did not live with the worker during any of the last 13 months.
LIST EACH MONTH IN WHICH second CHILD DID NOT LIVE WITH THE WORKER	Text	List each month in which the second child did not live with the worker during the last 13 months.
Name and Address for the person with whom second child lived	Text	Provide the name and address of the person with whom the second child lived during the months they did not live with the worker.
Relationship to child for person with whom second child lived	Text	Specify the relationship to the child for the person with whom the second child lived.
(Name of Child)	Text	Enter the full name of the child for whom you are applying for benefits.
(Name of Child)	Text	Enter the full name of the child for whom you are applying for benefits.
(Name of Child)	Text	Enter the full name of the child for whom you are applying for benefits.
Child Relationship
Child three's Relationship to Worker is Stepchild	CheckBox	Indicate if Child 3 is a stepchild of the worker. Check this box if the child is a stepchild.
Child three's Relationship to Worker is Dependent Grandchild	CheckBox	Indicate if Child 3 is a dependent grandchild of the worker. Check this box if the child is a dependent grandchild.
Child three's Relationship to Worker is other	CheckBox	Specify if Child 3 has a different relationship to the worker not listed. Check this box if the relationship is other.
Child four's Relationship to Worker is Legitimate	CheckBox	Indicate if Child 4 is a legitimate child of the worker. Check this box if the child is legitimate.
Child four's Relationship to Worker is Adopted	CheckBox	Indicate if Child 4 is an adopted child of the worker. Check this box if the child is adopted.
Child four's Relationship to Worker is Stepchild	CheckBox	Indicate if Child 4 is a stepchild of the worker. Check this box if the child is a stepchild.
Child four's Relationship to Worker is Dependent Grandchild	CheckBox	Indicate if Child 4 is a dependent grandchild of the worker. Check this box if the child is a dependent grandchild.
Child four's Relationship to Worker is other	CheckBox	Specify if Child 4 has a different relationship to the worker not listed. Check this box if the relationship is other.
Child six's Relationship to Worker is Legitimate	CheckBox	Check this box if Child 6's relationship to the worker is legitimate.
Child six's Relationship to Worker is Adopted	CheckBox	Check this box if Child 6's relationship to the worker is adopted.
Child six's Relationship to Worker is Stepchild	CheckBox	Check this box if Child 6's relationship to the worker is as a stepchild.
Child six's Relationship to Worker is Dependent Grandchild	CheckBox	Check this box if Child 6's relationship to the worker is as a dependent grandchild.
Child six's Relationship to Worker is other	CheckBox	Check this box if Child 6's relationship to the worker is other than the specified options.
Child Relationship to Worker
Child five's Relationship to Worker is Legitimate	CheckBox	Check this box if Child 5's relationship to the worker is legitimate.
Child five's Relationship to Worker is Adopted	CheckBox	Check this box if Child 5's relationship to the worker is adopted.
Child five's Relationship to Worker is Stepchild	CheckBox	Check this box if Child 5's relationship to the worker is as a stepchild.
Child five's Relationship to Worker is Dependent Grandchild	CheckBox	Check this box if Child 5's relationship to the worker is as a dependent grandchild.
Child five's Relationship to Worker is other	CheckBox	Check this box if Child 5's relationship to the worker is other than the specified options.
Child Status
Child 4, 17.5 or Older is Student	CheckBox	Indicate if Child 4, who is 17.5 years or older, is currently a student. Check this box if the child is a student.
Child 4, 17.5 or Older is Disabled	CheckBox	Indicate if Child 4, who is 17.5 years or older, is disabled. Check this box if the child is disabled.
Child 5, 17.5 or Older is Student	CheckBox	Check this box if Child 5 is 17.5 years or older and is a student.
Child 5, 17.5 or Older is Disabled	CheckBox	Check this box if Child 5 is 17.5 years or older and is disabled.
Child 6, 17.5 or Older is Student	CheckBox	Check this box if Child 6, who is 17.5 years or older, is a student.
Child 6, 17.5 or Older is Disabled	CheckBox	Check this box if Child 6, who is 17.5 years or older, is disabled.
Child Status Changes
Custody Change - Report if a child for whom you are filing or who is in your care dies, leaves your care or custody, or changes address. • The child age 13 or older has an unsatisfied felony or arrest warrant for more than 30 continuous days for flight to avoid prosecution or confinement, escape from custody, or flight-escape. • A student, age 18 or over, stops attending school, reduces school attendance below full-time, changes schools, or is paid by an employer to attend school. • If the worker and stepchild's parent divorce. Benefits are not payable to a stepchild beginning with the month after the month the worker and the stepchild's parent divorce. Promptly return any benefit payment received on behalf of the stepchild for the months after the month the divorce becomes final. • The child is confined for more than 30 continuous days to a jail, prison, penal institution or correctional facility for conviction of a crime or confined to a public institution by a court order in connection with a crime. • Change in Marital Status - Marriage, divorce, or annulment of marriage. You must report marriage even if you believe that an exception applies. • Disability Applicants - In addition to the applicable reporting requirements listed above: 1. The disabled adult child returns to work (as an employee or self-employed) regardless of amount of earnings. 2. The disabled adult child's condition improves. An agency in your State that works with us in administering the Social Security disability program is responsible for making the disability decision on the child's claim. In some cases, it is necessary for them to get additional information about the child's condition or to arrange for the child to have a medical examination at Government expense	Text	Provide details about any changes in custody, address, school attendance, marital status, or legal status of the child for whom you are filing. This includes reporting if the child is confined, changes schools, or if there is a change in the marital status of the worker and stepchild's parent.
Children's Information
NAME OF CHILD NOT LIVING WITH THE WORKER	Text	Enter the name of the child who was not living with the worker at the time of their death.
Name of second child not living with the worker	Text	Enter the name of the second child who was not living with the worker at the time of their death.
Children's Living Situation
No	CheckBox	Check this box if the answer is 'No' to the question regarding the living situation of the children at the time of the worker's death.
29. Were all the children in item 3 living with the Worker at the time of death? Yes	CheckBox	Check this box if all the children listed in item 3 were living with the worker at the time of their death.
No (If "No," enter the following information in the table)	CheckBox	Check this box if not all children were living with the worker at the time of death. If checked, additional information must be provided in the table.
Name and address of person with whom first child was living	Text	Provide the name and address of the person with whom the first child was living at the time of the worker's death.
Relationship to child of person with whom first child was living	Text	Specify the relationship to the child of the person with whom the first child was living.
Name and address of person with whom second child was living	Text	Provide the name and address of the person with whom the second child was living at the time of the worker's death.
Relationship to child of person with whom second child was living	Text	Specify the relationship to the child of the person with whom the second child was living.
Claim Type
Form SSA-4-BK (01-2017) U F. Discontinue Prior Editions. Social Security Administration Application for Child's Insurance Benefits. O M B Number 0960-0010 Page 1 of 9. The Privacy Act and Paperwork Reduction Act Statements are located on Page 7. T E L	CheckBox	Indicate if this application is for a life claim related to the child's insurance benefits.
(Do not write in this space) Life Claim	CheckBox	Check this box if the application is for a life claim. Do not write in this space.
Death Claim	CheckBox	Indicate if this application is for a death claim related to the child's insurance benefits.
Claimant Information
Some claims may take longer if additional information is needed. In the meantime, if you or any child(ren) changes address, or if there is some other change that may affect your claim, you or someone for you should report the change. The changes to be reported are listed below. 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. Below is a table with 2 columns and 4 rows. Column headers are Claimant and Social Security Claim Number. Claimant 1	Text	Enter the name of the first claimant for the child's Social Security benefits. This is the person on whose behalf the claim is being made.
SOCIAL SECURITY CLAIM NUMBER for Claimant 1	Text	Enter the Social Security Claim Number associated with Claimant 1. This number is used to track the claim.
Claimant 2	Text	Enter the name of the second claimant for the child's Social Security benefits, if applicable.
SOCIAL SECURITY CLAIM NUMBER for Claimant 2	Text	Enter the Social Security Claim Number associated with Claimant 2. This number is used to track the claim.
Claimant 3	Text	Enter the name of the third claimant for the child's Social Security benefits, if applicable.
SOCIAL SECURITY CLAIM NUMBER for Claimant 3	Text	Enter the Social Security Claim Number associated with Claimant 3. This number is used to track the claim.
Claimant 4	Text	Enter the name of the fourth claimant for the child's Social Security benefits, if applicable.
SOCIAL SECURITY CLAIM NUMBER for Claimant 4	Text	Enter the Social Security Claim Number associated with Claimant 4. This number is used to track the claim.
Contact Information
ADDRESS	Text	Enter the full address of the person or entity related to the application. This may be the address of the applicant or the child.
ADDRESS	Text	Provide the complete address, including street, city, state, and ZIP code, for correspondence related to this application.
TELEPHONE NUMBER (INCLUDE AREA CODE)	Text	Enter the telephone number, including the area code, for contact purposes regarding this application.
Telephone Number(s) at Which You May be Contacted During the Day (Include Area Code)	Text	Provide the telephone number(s) where you can be contacted during the day, including the area code.
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)	Text	Enter the applicant's mailing address, including number, street, apartment number, P.O. Box, or rural route. If the residence address is different, enter it in the 'Remarks' section.
City and State	Text	Enter the city and state of the applicant's mailing address.
ZIP Code	Text	Enter the ZIP code of the applicant's mailing address.
County (if any) in which you now live	Text	Enter the county, if any, where the applicant currently resides.
Calling us TOLL FREE at 1-800-772-1213; • If you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or • Calling, visiting or writing your local Social Security office at the phone number and address above. For general information about Social Security, visit our web site at w w w.social security.g o v. For those under full retirement age, the law requires that a report of earnings be filed with SSA within 3 months and 15 days after the end of any taxable year in which the child earns more than the annual exempt amount. You may contact SSA to file a report for the child. Otherwise, SSA will use the earnings reported by the child's employer(s) and the child's self-employment tax return (if applicable) as the report of earnings required by law, to adjust benefits under the earnings test. It is your responsibility to ensure that the information you give concerning the child's earnings is correct. This is the end of the form. If you tab you will be taken to two links and if you tab again, you will be at the beginning of the form	Button	Contact information for reporting earnings and other changes to the Social Security Administration. Includes phone numbers and website details for general inquiries and specific reporting requirements.
Date Information
MONTH, DAY, YEAR	Date	Enter the date in the format MONTH, DAY, YEAR. This is likely related to a specific event or status change.
(Year)	Text	Enter the relevant year associated with the information you are providing, such as the year of a specific event or report.
Deceased Worker Information
PART II - INFORMATION ABOUT THE DECEASED. Complete items 18 through 26 only if the Worker is deceased. 18. (ay) Print date of birth of Worker Month, Day, Year	Date	Enter the date of birth of the worker, including month, day, and year, if the worker is deceased.
(b) Print Worker's name at birth if different from item 1 (a)	Text	Provide the worker's name at birth if it is different from the name provided in item 1(a), applicable only if the worker is deceased.
18. (c) Check (X) one for the Worker Male	CheckBox	Check the box to indicate the gender of the worker as male, applicable only if the worker is deceased.
Earnings Evidence
Page 5 of 9. 26. Check if applicable: I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid with full retroactivity	CheckBox	Check this box if you are not submitting evidence of the deceased's earnings that are not yet on their earnings record. Understand that these earnings will be included automatically within 24 months.
Earnings Expectation
EARNINGS INFORMATION FOR THIS YEAR 12. (ay) Do you expect the total earnings of any child in item 3 to be more than the exempt amount this year? (Count all earnings beginning with the first of this year and all anticipated earnings through the end of this year.) (If "Yes," answer (b).) Yes	CheckBox	Indicate whether you expect the total earnings of any child listed in item 3 to exceed the exempt amount this year. Select 'Yes' if applicable.
(If "No," go on to item 13.) No	CheckBox	Select 'No' if you do not expect the total earnings of any child listed in item 3 to exceed the exempt amount this year.
12b. This is a table with 3 columns and 3 rows. Column headers are NAME OF CHILD WHO EXPECTS TO EARN OVER THE EXEMPT AMOUNT THIS YEAR, EXPECTED EARNINGS OF CHILD, and LIST EACH MONTH (INCLUDING THE PRESENT MONTH) THAT CHILD DID NOT OR WILL NOT EARN MORE THAN $ blank line IN WAGES AND DID NOT OR WILL NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT. Enter amount for blank line	Number	Enter the amount for the blank line in the table that lists the name of the child who expects to earn over the exempt amount, their expected earnings, and the months they will not exceed the specified earnings.
Earnings Information
Page 3 of 9. If you are applying ONLY for a child age 18 or over who is disabled, omit items 11 through 14. In all other cases, answer items 11 through 14. EARNINGS INFORMATION FOR LAST YEAR (Do not complete if the Worker died this year) 11. ( ay) Did any child in item 3 earn more than the exempt amount last year? (If "Yes," answer (b).)Yes	CheckBox	Indicate whether any child listed in item 3 earned more than the exempt amount last year. Check 'Yes' if applicable.
(If "No," go on to item 12.)No	CheckBox	Indicate whether no child listed in item 3 earned more than the exempt amount last year. Check 'No' if applicable.
11b. Below is a table with 3 columns and 3 rows. Column headers are NAME OF CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR, TOTAL EARNINGS OF CHILD, and LIST EACH MONTH THAT CHILD DID NOT EARN MORE THAN $ blank line IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT. Enter amount for blank line	Number	Enter the exempt amount for the previous year. This is used to determine if a child's earnings exceeded this threshold.
NAME OF first CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR	Text	Enter the name of the first child who earned over the exempt amount last year.
TOTAL EARNINGS OF first CHILD	Number	Enter the total earnings of the first child who earned over the exempt amount last year.
LIST EACH MONTH THAT first CHILD DID NOT EARN MORE THAN $ Amount entered into the blank line in Number 11 IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month in which the first child did not earn more than the exempt amount in wages and did not perform substantial services in self-employment.
NAME OF second CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR	Text	Enter the name of the second child who earned over the exempt amount last year.
TOTAL EARNINGS OF second CHILD	Number	Enter the total earnings of the second child who earned over the exempt amount last year.
LIST EACH MONTH THAT second CHILD DID NOT EARN MORE THAN $ Amount entered into the blank line in Number 11 IN WAGES AND DID NOT PERFORM SUBSTANTIAL SERVICES IN SELF-EMPLOYMENT	Text	List each month in which the second child did not earn more than the exempt amount in wages and did not perform substantial services in self-employment.
NAME OF third CHILD WHO EARNED OVER THE EXEMPT AMOUNT LAST YEAR	Text	Enter the name of the third child who earned over the exempt amount last year.
Eligibility Criteria
CheckBox11	CheckBox	Select this checkbox if the condition specified in the form instructions applies to the child.
CheckBox11	CheckBox	Select this checkbox if the condition specified in the form instructions applies to the child.
CheckBox11	CheckBox	Select this checkbox if the condition specified in the form instructions applies to the child.
CheckBox11	CheckBox	Select this checkbox if the condition specified in the form instructions applies to the child.
Federal Benefits
22. (c) Has anyone (including the Worker) received, or does anyone expect to receive, a benefit from any other Federal agency? Yes	CheckBox	Check 'Yes' if anyone, including the worker, has received or expects to receive a benefit from any other Federal agency.
No	CheckBox	Check 'No' if no one, including the worker, has received or expects to receive a benefit from any other Federal agency.
Financial Information
DecimalField1	Number	Enter a decimal value related to the child's benefits or earnings, if applicable.
General
Female	CheckBox	Check this box if the child is female.
General Information
MONTH, DAY, YEAR	Date	Enter the date in the format Month, Day, Year.
MONTH, DAY, YEAR	Date	Enter the date in the format MONTH, DAY, YEAR.
CITY AND STATE	Text	Enter the city and state where the event occurred.
STATE OR FOREIGN COUNTRY	Text	Enter the state or foreign country related to the event or residence.
Guardian Information
Name and Address for Person with whom Child 1 now lives	Text	Enter the name and address of the person with whom the first child is currently living.
Relationship for Person with whom Child 1 now lives	Text	Specify the relationship of the person with whom the first child is living to the child.
Name and Address for Person with whom Child 2 now lives	Text	Enter the name and address of the person with whom the second child is currently living.
Relationship for Person with whom Child 2 now lives	Text	Specify the relationship of the person with whom the second child is living to the child.
Name and Address for Person with whom Child 3 now lives	Text	Enter the name and address of the person with whom the third child is currently living.
Relationship for Person with whom Child 3 now lives	Text	Specify the relationship of the person with whom the third child is living to the child.
Name and Address for Person with whom Child 4 now lives	Text	Enter the name and address of the person with whom the fourth child is currently living.
Relationship for Person with whom Child 4 now lives	Text	Specify the relationship of the person with whom the fourth child is living to the child.
Household Information
8 Are all the children in item 3 now living in the same household with you? Yes	CheckBox	Select 'Yes' if all the children listed in item 3 are currently living in the same household with you.
International Social Security
23. (ay) Did the worker have social security credits (for example, based on work or residence) under another country's social security system? (If "Yes,"answer (b).) Yes	CheckBox	Check 'Yes' if the worker has social security credits under another country's social security system.
(If "No," go on to item 24.) No	CheckBox	Check 'No' if the worker does not have social security credits under another country's social security system.
(b) List the country(ies)	Text	List the countries where the worker has social security credits.
Legal Information
(c) Briefly explain the circumstances which led the court to appoint a legal representative	Text	Briefly describe the reasons why a court appointed a legal representative for the child or children involved in this application.
Legal Representation
5.(ay) Is there a legal representative (guardian, conservator, curator, etc.) for any of the children in item 3? (If "Yes," complete (b) and (c).) Yes	CheckBox	Check 'Yes' if there is a legal representative (guardian, conservator, curator, etc.) for any of the children listed in item 3. If 'Yes,' complete sections (b) and (c).
(If "No," go on to item 6.) No	CheckBox	Check 'No' if there is no legal representative for any of the children listed in item 3. If 'No,' proceed to item 6.
Living Arrangements
(If "No," enter the following information in the table about each child not living with you. If uncertain as to the whereabouts of any of these children, explain in "Remarks".) No	CheckBox	Check this box if none of the children listed are living with you. If you check 'No,' you will need to provide additional information about each child not living with you.
Page 4 of 9. 16 Have all of the children in item 3 lived with the Worker during each of the last 13 months (counting the present month)? Yes	CheckBox	Indicate whether all the children listed in item 3 have lived with the worker during each of the last 13 months, including the present month. Check 'Yes' if they have.
No (If "No," enter the information requested below in the table.)	CheckBox	Check 'No' if any of the children listed in item 3 have not lived with the worker during each of the last 13 months. Provide additional information in the table if 'No' is selected.
Marital Status
9 Has any child in item 3 ever been married? (If "Yes," enter the information requested below.) Yes	CheckBox	Check this box if any child listed in item 3 has ever been married. If 'Yes,' you will need to provide additional information.
Marriage Details
	Text	Provide details on how the marriage ended, such as divorce, annulment, or death of a spouse.
Date Marriage Ended (Month, day, year)	Date	Enter the date when the marriage ended, including the month, day, and year.
Marriage Information
Date of Marriage (Month, day, year)	Date	Enter the date of marriage in the format Month, Day, Year.
Parental Information
6 Are you the natural or adoptive parent of the person(s) for whom you are filing? Yes	CheckBox	Select 'Yes' if you are the natural or adoptive parent of the child or children for whom you are applying for benefits.
No	CheckBox	Select 'No' if you are not the natural or adoptive parent of the child or children for whom you are applying for benefits.
Payment Options
Enroll in Direct Express	CheckBox	Check this box if you wish to enroll in the Direct Express program for receiving benefits.
Direct Deposit Refused	CheckBox	Check this box if you refuse direct deposit of the benefits.
Post-Award Information
AFTER YOU RECEIVE A NOTICE OF AWARD	Text	This section provides guidance and information for actions to take after you receive a Notice of Award for the child's insurance benefits. It is crucial to follow these instructions to ensure proper handling of the benefits.
Pre-Award Information
BEFORE YOU RECEIVE A NOTICE OF AWARD	Text	This section contains information and instructions relevant to the period before you receive a Notice of Award for the child's insurance benefits. Review this to understand the steps and requirements prior to award notification.
Previous Applications
No	CheckBox	Check this box if the answer is 'No' to the question about whether anyone has previously filed an application for benefits on behalf of any child listed in item 3.
10. Has anyone ever before filed an application with the Social Security Administration for monthly benefits on behalf of any child in item 3? (If "Yes," enter below the name(s) of the child(ren) and the name(s) and Social Security number(s) of the person(s) on whose earnings record any other claim was based in the table.) Yes	CheckBox	Check this box if the answer is 'Yes' to the question about whether anyone has previously filed an application for benefits on behalf of any child listed in item 3.
No	CheckBox	Check this box if the answer is 'No' to the question about whether anyone has previously filed an application for benefits on behalf of any child listed in item 3.
Privacy and Legal Information
Page 7 of 9. Privacy Act Statement Collection and Use of Personal Information. Sections 202, 205, 223, 1818, 1836, and 1840 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed, or could result in the loss of benefits. We will use the information you provide to determine eligibility for monthly benefits or insurance coverage and to authorize payments to the children of retired, disabled, or deceased workers. We may also share your information for the following purposes, called routine uses: 1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash income maintenance or health maintenance programs (including programs under the Act). 2. To contractors and other Federal agencies, as necessary, for the purpose of assisting 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. 3. To the Centers for Medicare & Medicaid Services, for the purpose of administering Medicare Part Ay, Part B, Medicare Advantage Part C, and Medicare Part D. 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. Ay list of additional routine uses is available in our Privacy Act System of Records Notice (S O R N) 60-0089, entitled Claims Folder System, and 60-0321, entitled Medicare Database (M D B) File. Additional information and a full listing of all our S O R Ns are available on our website at w w w.social security.g o v/f o i ay/bluebook. 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 (O M B) control number. We estimate that it will take about 12 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	Text	This section provides the Privacy Act Statement and explains how your personal information will be used and shared by the Social Security Administration. It is important to read and understand this information before proceeding with the application.
Reporting Instructions
HOW TO REPORT You can make your reports by telephone, mail, or in person, whichever you prefer. If you are awarded benefits and one or more of the above change(s) occur, you should report by: • Visiting the section "What You Can Do Online" at our web site at w w w.social security.g o v	Button	Instructions on how to report changes related to the child's benefits. You can report by telephone, mail, or in person, and also online through the Social Security website.
Signature
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)	Text	Sign the form with your first name, middle initial, and last name using ink.
Date (Month, Day, Year)	Date	Enter the date of signing in the format Month, Day, Year.
Supplemental Security Income
17. If any of the children in item 3 are within 2 months of age 65 or older, blind or disabled, do you want to file on his/her behalf for Supplemental Security Income? Yes	CheckBox	Indicate if you want to file for Supplemental Security Income on behalf of any child listed in item 3 who is within 2 months of age 65 or older, blind, or disabled. Check 'Yes' if applicable.
No	CheckBox	Indicate if you do not want to file for Supplemental Security Income on behalf of any child listed in item 3 who is within 2 months of age 65 or older, blind, or disabled. Check 'No' if applicable.
Witness Information
1. Signature of Witness	Text	Provide the signature of the first witness to the application.
Address (Number and Street, City, State, and ZIP Code)	Text	Enter the address of the first witness, including number, street, city, state, and ZIP code.
2. Signature of Witness	Text	Provide the signature of the second witness to the application.
ZIP Code)	Text	Enter the ZIP code of the second witness's address.
Worker Information
FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter the first name, middle initial, and last name of the worker.
(b) PRINT Worker's Social Security number	Text	Enter the Social Security number of the worker.
Name of Worker for Child 1	Text	Enter the name of the worker associated with the first child for whom a previous application for benefits was filed.
Social Security Number of Worker for Child 1	Text	Enter the Social Security Number of the worker associated with the first child for whom a previous application for benefits was filed.
Name of Worker for Child 2	Text	Enter the name of the worker associated with the second child for whom a previous application for benefits was filed.
Social Security Number of Worker for Child 2	Text	Enter the Social Security Number of the worker associated with the second child for whom a previous application for benefits was filed.
Name of Worker for Child 3	Text	Enter the name of the worker associated with the third child for whom a previous application for benefits was filed.
Social Security Number of Worker for Child 3	Text	Enter the Social Security Number of the worker associated with the third child for whom a previous application for benefits was filed.
Name of Worker for Child 4	Text	Enter the full name of the worker associated with Child 4. This is the person whose earnings record is being used to apply for benefits.
Social Security Number of Worker for Child 4	Text	Enter the Social Security Number of the worker associated with Child 4. This is required to identify the worker's earnings record.
WORKER'S NAME (If surname differs from name of claimant(s).)	Text	Enter the worker's full name, especially if it differs from the surname of the claimant(s). This is the person whose earnings record is being used for the child's benefits.
Worker's Earnings History
24 (ay) Did the worker have wages or self-employment income covered under Social Security in all years from 1978 through last year? (If "Yes", skip to item 25.) Yes	CheckBox	Indicate whether the worker had wages or self-employment income covered under Social Security for all years from 1978 through the last year. Select 'Yes' if applicable.
(If "No," answer (b).) No	CheckBox	Indicate whether the worker did not have wages or self-employment income covered under Social Security for all years from 1978 through the last year. Select 'No' if applicable.
(b) List the years from 1978 through last year in which the worker did not have wages or self-employment income covered under Social Security	Text	List the specific years from 1978 through the last year in which the worker did not have wages or self-employment income covered under Social Security.
	Text	Provide any additional information related to the worker's earnings or employment history as required.
	Text	Provide any additional information related to the worker's earnings or employment history as required.
Worker's Employment History
21. Did the Worker work in the railroad industry for 5 years or more? Yes	CheckBox	Check 'Yes' if the worker worked in the railroad industry for 5 years or more.
No	CheckBox	Check 'No' if the worker did not work in the railroad industry for 5 years or more.
Worker's Health and Disability
Answer item 28 ONLY if the Worker died prior to age 66 and within the past 4 months. 28. (ay) Was the Worker unable to work because of a disabling condition at the time of death? (If Yes, answer (b)) Yes	CheckBox	Indicate whether the worker was unable to work because of a disabling condition at the time of death, applicable only if the worker died prior to age 66 and within the past 4 months. Select 'Yes' if applicable.
Worker's Military Service
22. (ay) Was the Worker 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 (b) and (c).) Yes	CheckBox	Check 'Yes' if the worker was in active military or naval service after September 7, 1939, and before 1968.
(If "No," go on to item 23.) No	CheckBox	Check 'No' if the worker was not in active military or naval service after September 7, 1939, and before 1968.
FROM (month-year)	Date	Enter the start date of the worker's military service in the format month-year.
TO (month-year)	Date	Enter the end date of the worker's military service in the format month-year.
Worker's Social Security Applications
27. (ay) Did the Worker ever file an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare? (If "Yes," answer (b) and (c).) Yes	CheckBox	Indicate whether the worker ever filed an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare. Select 'Yes' if applicable.
(If "No" or "Unknown," go on to item 28.) No	CheckBox	Indicate whether the worker did not file an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare. Select 'No' if applicable.
(If "No" or "Unknown," go on to item 28.) Unknown	CheckBox	Indicate if it is unknown whether the worker filed an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare.
(b) Enter name of person(s) on whose Social Security record other application was filed	Text	Enter the name of the person(s) on whose Social Security record another application was filed.
27. (c) Enter Social Security number of person named in (b)	Text	Enter the Social Security number of the person named in the previous field (b).
(If "Unknown," so indicate.)	CheckBox	Indicate if the Social Security number of the person named in the previous field is unknown.

Form SSA-4-BK, Application for Child's Insurance Benefits Instructions