Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697630924445.pdf (Antigua and Barbuda)
ANTIGUA & BARBUDA SOCIAL SECURITY BOARD Survivor’s Benefit Requirements Widow born in Antigua & Barbuda Death Certificate and Identification (ID) for the deceased Valid Passport and Registered Marriage Certificate or Valid Government issued identification (ID), Birth Certificate and Marriage Certificate Banking information: name of bank or credit union account number and name on account Widow not born in Antigua & Barbuda Death Certificate and Identification (ID) for the deceased Valid Passport and Registered Marriage Certificate Banking information: name of bank or credit union account number and name on account NB.
In addition to the Survivor’s Application Form the widow must also submit the appropriate life certificate based on where she resides.
Surviving child/children Death Certificate and Identification (ID) for the deceased Birth Certificate and Baptismal Certificate for the surviving child/children Letter / School Form from the school that the child/children attend Valid Passport or Valid Government issued identification (ID) for the parent or legal guardian making application If legal guardian necessary, registered legal documents are required Banking information: name of bank or credit union account number and name on account Please note that all original or notarized documents are required in order for the application to be processed.
Application must be received within one (1) year from the date of death of the insured person.
For further information please contact Tel: (268) 736-3000/1/2/3 Fax (268) 481-3090 customerserv@socialsecurity.gov.ag socsec@socialsecurity.gov.ag ANTIGUA & BARBUDA SOCIAL SECURITY CLAIM FOR SURVIVORS BENEFIT PARTICULARS OF DECEASED INSURED PERSON: SOCIAL SECURITY NUMBER: _________________ NAME: ______________________________ (Surname) _______________________________________________ (Other Names) LAST ADDRESS: __________________________________ DATE OF BIRTH: _____________________________ __________________________________________________ DATE OF DEATH:____________________________ NAME OF LAST EMPLOYER_______________________________________________________________________ Was the deceased in receipt of a Benefit from Social Security?
Yes No _____________________________ (Type of Benefit) Did the deceased worked in any Caricom Territory or Canada?
Yes No If yes please provide information below: YEARS OF EMPLOYMENT From To NAME OF EMPLOYERS COUNTRY PARTICULARS OF CLAIMANT WHO IS THE WIDOW, INVALID WIDOWER OR COMMON-LAW SPOUSE NAME: __________________ ______ _________________________________ RELATION: _________________ (Surname) (Other Names) ADDRESS: _________________________________________________ DATE OF BIRTH: ____________________ ___________________________________________________________ SOCIAL SECURITY #_________________ DATE OF MARRIAGE________________EMAIL:___________________________ TEL.
# ( ) ______________ At the time of death were you living with the deceased?

Yes No if yes how long ____________________ Are you receiving any benefit from Social Security?

Yes No ________________ SS#______________ (Type of Benefit) If claimant is common law spouse, she must produce documentary evidence (3letters) to support this.

Warning: Anyone who knowingly makes any false representation for the purpose of receiving benefit is guilty of an offence which is punishable by law.
Please make Benefit Payable to: Name: ____________________________________________ A/C Type_________ A/C#______________________ Name of Bank: ____________________________________ Address: ____________________________________ If payee is different to the applicant, please complete the following: Name: ____________________________________________ Telephone # ( ) ___________________________ Address_________________________________________________________________________________________ NOTE: Any payment received and or cashed after the date of death must be reimbursed to the Social Security Office before the benefit can be processed.
ALL original documents or notarized copies are required in order for the application to be processed.

The application must be received with ALL the required documents within one (1) year from the date of death of the insured person.
___________________________________________________________ __________________________________ (Signature of Claimant) (Date) ___________________________________________________________ __________________________________ (Signature of Interviewer) (Date) FOR CHILDREN AND OVERSEAS APPLICANTS PLEASE SEE OVER-LEAF PARTICULARS OF CHILDREN UP TO AGE 16 OR AGE 18 AND STILL ATTENDING SCHOOL NAME CHILD/CHILDREN SEX NAME OF PARENT/GUARDIAN D M Y DATE OF BIRTH PARTICULARS BIRTH CERTIFICATE NO PAGE COUNTRY OF BIRTH Name of claimant: ________________________________________ Relationship to child: ____________________ Address: ________________________________________________ Telephone # ( ) _____________________ _________________________________________________________ Email: _________________________________ Please make Benefit Payable to: Name: __________________________________________ A/C Type_________ A/C#_________________________ Name of Bank: _____________________________________ Address: ____________________________________ If payee is different to the applicant, please complete the following: Name: ____________________________________________________ Telephone # ( ) ____________________ Address: __________________________________________________ Relationship to Claimant: ________________ ________________________________________________________________________________________________ ___________________________________________________ ______________________________ (Signature of Claimant) (Date) ___________________________________________________ ______________________________ (Signature of Interviewer) (Date) If payment is not payable to a bank in Antigua and Barbuda, the following information is required: Wire Transfer Information Bank Name: Bank Address: Bank Routing Number: Bank Swift Code: Name on Account: Account Number: Payee Physical Address: __________________________________ Signature of Applicant ___________________ Date ___________________________________ Signature of Notary Date ___________________ Notary Stamp or Seal OFFICAL USE: ___________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ANTIGUA & BARBUDA SOCIAL SECURITY BOARD LONG STREET, P.O .Box 1125 ST. JOHN’S ANTIGUA TEL: (268) 736-3000/1/2/3 FAX (268) 481-3090 E –mail: customerserv@socialsecurity.gov.ag LOCAL LIFE CERTIFICATE FULL NAME of PENSIONER: __________________________________________________________________ Social Security # Pension # Type of Pension: Age Invalidity Survivors Old Age Assistance Signature of Pensioner______________________________________ Date_________________________ Life Certificate form TO BE CERTIFIED BY ONE OF THE PERSONS ON THE OVER-LEAF ______________________________________________________________________ TO BE CERTIFIED BY ANY OF THE FOLLOWING PERSONS BY TICKING SPECIFIED PROFESSION: Notary Public Medical Practitioner Bank Official Minister of Religion Social Security Staff Lawyer Registered Nurse School Principal Member of Parliament Retired Senior Soc.
Sec Staff I, the undersigned, hereby certify that: ___________________________________________________________________________ Whose signature is affixed on the over-leaf was alive on the _____________________ day of _______________ 20 _____________ _________________________________________________ _____________________________________________ Name of Church Signature (Applicable to Minister of Religion) ______________________________________________ Print Name ______________________________________________ Profession OFFICIAL STAMP ______________________________________________ Life Certificate Form Date ANTIGUA & BARBUDA SOCIAL SECURITY BOARD HEAD OFFICE ST. JOHN’S ANTIGUA P.O.
BOX 1125 Email: customerserv@socialsecurity.gov.ag TELEPHONE: 268-736-3000 FAX: 268-481-3090 SCHOOL ATTENDANCE CERTIFICATION (ONLY FOR USE IN SCHOOLS IN ANTIGUA & BARBUDA) NAME OF STUDENT (BENEFICIARY):_______________________________ SS# OF DECEASED PARENT: ______________________ PNO: ______________________ TO BE COMPLETED BY PRINCIPAL OF SCHOOL NAME OF SCHOOL: __________________________________________________________ I hereby certify that ________________________________________ is presently a student (NAME OF STUDENT) of the above named school for the period _____________________ to __________________.
Name of Principal _____________________________________________________________ Signature:_________________________________ Date:_____________________________________ ______________________________ (AFFIX SCHOOL STAMP OR SEAL) For official use only Entered by:__________________________________ Date:____________________________