Application for Disability and/or Death Benefit for Survivor and Dependent Children

Protect your personal information!

You can enter your information directly into this form and save it as you go. If you are using a public computer that can also be used by other people, such as a library computer, you have to be extra careful. Remember to protect your personal information if you are filling out this form on a shared computer, because your information could be seen by others.

If you are using a shared, public computer please make sure you do not leave the computer while filling out the form. Do not save a completed form directly onto the computer, and before you leave, make sure you clear the browser's cache and close down the browser. If you do this, no one else can see any personal information you may have entered.