Certification of Death of A Social Security Beneficiary

NOTE: The form below is for Social Security related inquiries only. Any questions regarding other issues, including questions about visas or passports, will be deleted, and you will not receive a response.

Last Name of deceased:

First Name(s) of deceased:

Social Security Number:

(Last 4 digits)

Date of Death:

Reporters Information

First and Last Name of Reporter:

Relationship to deceased:

Mailing Address:

Daytime Phone:

Evening Phone:

Mobile / Cell:

Your Email address:

Additional Information:

The information you provide is used solely by the Regional Federal Benefits Unit. In order to process certain types of requests, we may have to ask for your Social Security Number (SSN) or the last 4-digits thereof, your date of birth, or your banking information. You may decline to provide such information, but that could result in a slower response from our benefits team. Please be aware that this form and e-mail are not secure and any information you send via this form is not guaranteed to be safe from potential loss or interception. Any information provided on our web form is not retained and is used only in order to process your current request or answer your current questions. We will remove any sensitive information from your e-mail before we reply. The Regional Social Security Office works in accordance with SSA procedures as well as the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) and the Privacy Act of 1974. You can read our full privacy statement at http://www.socialsecurity.gov