SSA-4169 1988-2025 free printable template
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BURIAL RESOURCE STATEMENT NAME (Individual or Parent): SOCIAL SECURITY NUMBER: NAME (Spouse or Parents Spouse): SOCIAL SECURITY NUMBER: RE: (Description of Resource(s)) designated as funds for the
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How to fill out SSA-4169
How to fill out SSA-4169
01
Obtain the SSA-4169 form from the Social Security Administration (SSA) website or local office.
02
Write your personal information at the top, including your name, Social Security number, and address.
03
Answer all questions clearly and accurately, ensuring that you understand what each question is asking.
04
If the question does not apply to you, write 'N/A' or 'not applicable.'
05
Review the completed form for any errors or missing information before submission.
06
Sign and date the form at the designated area.
07
Submit the completed form to the SSA as instructed, either by mailing it or delivering it in person.
Who needs SSA-4169?
01
Individuals who are applying for Social Security disability benefits or are involved in a Disability Insurance case may need to complete the SSA-4169 form.
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People Also Ask about
What documents are needed for Social Security survivor benefits?
Documents you may need to provide Proof of the worker's death; Birth certificate or other proof of birth; Proof of U.S. citizenship or lawful alien status if you were not born in the United States [More Info]; U.S. military discharge paper(s) if you had military service before 1968;
How do I get Form 10 Social Security?
If you can't find the form you need, or you need help completing a form, please call us at 1-800-772-1213 (TTY 1-800-325-0778) or contact your local Social Security office and we will help you.
What is a form SSA 4169?
Form SSA-4169 is a locally reproducible form for obtaining acknowledgement of an individual's or deemor's understanding that excluded burial funds must be kept separately identifiable and that there may be a penalty for misusing the funds.
Is there a burial benefit from Social Security?
If you (or your spouse) own life insurance polices or have other burial arrangements in addition to your $1,500 burial funds, some of the money in the burial fund may count toward the resource limit of $2,000 for an individual or $3,000 for a couple.
How much does Social Security allow for funeral expenses?
DOES A BURIAL FUND COUNT AS A RESOURCE FOR SSI? Generally, you and your spouse can set aside up to $1,500 each to pay for burial expenses. In most cases, this money will not count as a resource for Supplemental Security Income (SSI).
How do I claim funeral expenses from Social Security?
You can apply for benefits by calling our national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) or by visiting your local Social Security office. An appointment is not required, but if you call ahead and schedule one, it may reduce the time you spend waiting to apply.
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What is SSA-4169?
SSA-4169 is a form used by the Social Security Administration to gather information about work history and earnings from individuals who are applying for Social Security disability benefits.
Who is required to file SSA-4169?
Individuals applying for Social Security disability benefits are required to file SSA-4169 as part of their application process.
How to fill out SSA-4169?
To fill out SSA-4169, applicants need to provide information regarding their work history, including names of employers, job titles, dates of employment, and earnings. The form must be completed accurately and signed.
What is the purpose of SSA-4169?
The purpose of SSA-4169 is to collect detailed employment and earnings information from applicants to assess their work capacity and eligibility for disability benefits.
What information must be reported on SSA-4169?
The information that must be reported on SSA-4169 includes the names and addresses of employers, dates of employment, job titles, and the amounts earned during each employment period.
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