Form SSA-753 Statement Regarding Marriage

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB NO. 0960-0017

TOE 420

STATEMENT REGARDING MARRIAGE
All questions must be answered or marked "Unknown." If you need more space for answers, continue them
under "Remarks" on reverse side.
PRIVACY ACT NOTICE: The Social Security Administration is authorized to collect the information on this form under section 216(h)(1)(A) of the Social Security
Act. Giving us this information is voluntary. You do not have to do it, but your cooperation is needed to help establish the applicant's eligibility to Social
Security benefits. The Social Security Administration will use the information on this form to determine if a marital relationship exists so that an accurate
determination may be made regarding entitlement to spouse's benefits. We may routinely give out the information on this form without your consent for a
variety of reasons.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State,
or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government.
The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to
learn more about this, contact any Social Security Office.

See Revised PRA, Attached

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 9 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 telephone directory or you may call Social Security at 1-800-772-1213. You
may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time

Print Name of Wage Earner or Self-Employed Person
(Herein referred to as the "Worker".)

Enter His (Her) Social Security Number

Print Name of Applicant

I understand that this statement will be considered in connection with an application by the applicant named
above for payment of benefits under the provisions of Title II of the Social Security Act, as amended, based on
the earnings of the Worker named above.
Print Your Full Name (First name, middle initial, last name)

1. What is your relationship to the Worker? (Mother, child, cousin, etc. — if not related, state "None.")
To the Applicant? (Mother, child, cousin, etc. — if not related, state "None.")
2. How long have you known the Worker?

The Applicant?

3. How often and on what occasions did you meet the Worker?

The Applicant?

4. To your knowledge, were (are) the Worker and Applicant generally known as
husband and wife?
5. Did (do) you consider them husband and wife?

Yes

No

Yes

No

Give facts and explain fully the reasons for your belief:

Form SSA-753 (8-2004)

EF (08-2004)

(Over)

6. Did you hear them refer to each as husband and wife?

Yes

No

Yes

No

If "Yes," when and where?

7. In your opinion, did (do) they maintain a home and live together as husband and wife?
If ''Yes,'' where and when?
CITY OR TOWN

DATES

STATE

FROM—

TO—

8. To your knowledge, did they live together continuously?
If "No," explain.

9. To your knowledge, has either the Worker or the Applicant entered into any other marriage?
If ''Yes, '' give the following information regarding all such marriages.
STATE WHETHER WORKER
OR APPLICANT

TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

HOW MARRIAGE
TERMINATED

Yes

No

Yes

No

DATE AND PLACE
MARRIAGE TERMINATED

(This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

Remarks:

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.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
Telephone Number

SIGN
HERE
Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)

Area Code

ZIP Code

City and State

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the person making the statement must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

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

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

Form SSA-753 (8-2004)

EF (08-2004)

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 9
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
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.