TN 23 (07-90)
SI 01130.414 Form SSA-4169 (Burial Resource Statement)
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. It also reminds people of their reporting responsibilities in connection with the exclusion.
1. Number of Forms Needed
a. Individual With or Without a Spouse
Complete only one form.
b. Parental Deeming
Complete one form for the child or parent(s) as appropriate, if only the child or the parent(s) has excluded burial funds.
Complete two forms if both the child and the parent(s) have excluded burial funds.
2. Form Distribution
Distribute the completed, signed form as follows:
C. Exhibit — form SSA-4169
View PDF Version