104Formonly - Form template

Sep 19, 2026

Upload by Hazel

Personal information form capturing identity and contact details. Fields include last name, first name, middle initial, date of birth in MM/DD/YYYY format, Social Security number, and mailing address with phone number. It also supports deceased status and includes driver license or state ID references such as state of issue, last 4 characters of ID number, and date of issuance. For married applicants, it provides spouse information including spouse last name, first name, middle initial, and spouse SSN.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Applicant Identity

Deceased and ID Details

Spouse Information

Mailing Address

| Your Last Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Your First Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Middle Initial | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Date of Birth (MM/DD/YYYY) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | SSN | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Deceased | | | | | | | | | | | | Enter the following information from your current driver license or state identification card. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | State of Issue | | | | | | | | | | Last 4 characters of ID number | | | | | | | | | | | | | | | | | | Date of Issuance | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | If Joint, Spouse’s Last Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Spouse’s First Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Middle Initial | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Date of Birth (MM/DD/YYYY) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Spouse’s SSN | | | | | | | | | |

FAQs

What personal details does this form collect for the applicant?

It collects last name, first name, middle initial, date of birth (MM/DD/YYYY), and the applicant’s Social Security number. It also includes mailing address and phone number.

How does the form handle deceased applicants?

It includes a “Deceased” section with instructions to enter information from the current driver license or state identification card, including state of issue, last 4 characters of the ID number, and date of issuance.

What spouse information is requested on this form?

It asks for the spouse’s last name, first name, middle initial, and spouse SSN. For deceased spouse entries, it also requests state of issue, last 4 characters of ID number, and date of issuance.

Sep 19, 2026

Upload by Hazel