Form SSA-3 Marriage Certification

Form Approved
SOCIAL SECURITY ADMINISTRATION

MARRIAGE CERTIFICATION
SOCIAL SECURITY NUMBER

PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

I am the spouse of the person named below, who has applied for insurance benefits under the Title II of the Social Security Act,
as presently amended.
NAME OF SPOUSE (First Name)
(Maiden Name, if applicable)
(Last Name)

1. Indicate whether your present marriage was performed by:

o

Clergyman or Authorized Public Official

2. Were you married before your present
marriage?
TO WHOM MARRIED

II

o
o

Other (Explain)
Yes

(If "yes", give the following information
about each of your previous mamages.)

WHEN (Month, Day, Year)

WHERE (City and State)

Year}

WHERE (City and State)

P M
R A HOW MARRIAGE ENDED
E R
V R

I

I

OA
U G

S E

B

MARRIAGE PERFORMED BY:
Clergyman or Public Official
Other (Explain in "REMARKS"'

Spouse's Social Security Number (If none or unknown, so indicate)
TO WHOM MARRIED

GIVE DATE OF DEATH IF SPOUSE IS
DECEASED

TE OF BIRTH (or age)

II

--­

I

-­

I

---­

WHEN (Month, Day, Year)

WHERE (City and State)

R A HOW MARRIAGE ENDED
E R
V R

WHEN (Month, Day, Year)

WHERE (City and State)

I

SPOUSE'S DATE OF BIRTH (or age)

GIVE DATEOF DEATH IF SPOUSE IS
DECEASED

P M

I

OA
U G

S E

B

MARRIAGE PERFORMED BY;
Clergyman or Public Official
Other (Explain in "REMARKS"'
Spouse's Social Security Number

(If none or unknown, so indicate)

II

--­

I

-­

I ---­

REMARKS: (Use this space and the reverse of this form for information about any other previous marriages, if necessary)

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
~~S~IG~N=A~T~U~RE~O~F~W~A~G~E~EcA~R~N~ER~O~RwS~E~L~F-~E~M~P~L~O~Y~ED~P~E~RS~O~N~__________~DATE(Mont~Da~ Yea~
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)

SIGN ...........

TELEPHONE NUMBER (Area Code)

HERE ...........

MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, or Rural Route)

Witnesses are required ONLY if this statement has been signed by mark (Xl above. If signed by mark (Xl, two witnesses to
the si nin who know the wa e earner or self-em 10 ed erson must si n below, ivin their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA·3 (4·2003) EF (08-2008) Destroy Prior Editions IReverse

ADDRESS (Number and Street, City, State and ZIP Code)

he Social Securi Administration' s

authoriz to collect the info ation on this f,
under sectio 205(a) of the Soc al

Security ct. While it is vol ntary for you to furnish the info ation, we may n t be able

to pay be efits to your spo e unless you giv: us this inform

We ma)j also use the info
records by com uter.
Matchi g programs comn e our records ith those of oth Federal, State, r local
ent agencies. M y agencies rna use matching pr grams to fmd or prove that a
qualifies for ben ts paid by the ederal governm 1. The law allo s us to do this
you do not agre to it.
Expl ations about th e and other rea ns why inform ion you provide s may be used or
give out are availabl in Social Secu y offices. If yo want to learn m re about this,
con ct any Social S urity office.
Paperwork Reduction Act Statement - This information collection meets the requirements
of 44 U. S. C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995.
You do not need to answer these questions unless we display a valid Office of Management
and Budget control number. We estimate that it will take about 5 minutes to read the
instructions, gather the facts, and answer the questions. SEND THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under
U. S. Government agencies in your telepbone directory or you may call Social Security
at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Form SSA·3 (4-2003) EF (08·2008)

The following revised Privacy Act Statement will be inserted into the form at its
next scheduled reprinting:

Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to determine the identity of your
spouse.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent us from paying benefits to your spouse.
We rarely use the information you supply for any purpose other than for determining the
identity of a spouse. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research and audit activities necessary to assure the
integrity and improvement of Social Security programs' (e.g., to the Bureau of
the Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person's eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.