TN 23 (07-90)

A. Introduction

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.

B. Procedure

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:

• a photocopy to the individual (or deemor, as applicable); and

• the original in the claims file.

C. Exhibit — form SSA-4169

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