Form SSA-2 Application for Wife's or Husband's Insurance Benefits

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APPUCATDN FOR WIFE% DR HUSBAND'S lN8URANa BEfWEFhg
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FIRST NAME. MlDDLE INNIL, LAST HAME

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FIRST NAME. MIDDLE INTIAL, LAST W

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do you nem a p a c ~ w m~ buse SSA's lnbrdphone eerv197

& m k qurUon S lfEn&st~ Is not your pnhndlmnguage. Mh.ml..go to h6.

(a) Am you a US. &n?

(b) Have yar used any other name@)?

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(c)
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Haw you used any other Sodal SearMy number($)
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No

W NOT ANSWER QUESllON 10 IF YOU ARE ONEYEAR PAST F U U RmRElWNT AGE OR OLDER.
GO ON TO a u E s T m ti.

IMONTW. YEAR)

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(b) ~ l a c s m 3 ~ ~ n e p d , b b c * t a ~ ~ ~ ~ ~ o ( 1 s a y s a r ~ n wNONE
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MEDICARE INFORMATION
Wthied.in bspprcvedendyauare.tlllentit&d to beneRtsatege86,ywrwiYsutometicslly&W~PartA

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REMARKS (Yw may ut.thk .p&.kv any uplarudkns. If you mod

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SIGNATURE OF APPLICANT

Dab (Uonth. di;y. year)

TELEPHONE NUMBER@)
TOCAUIFYOUHWEA
QUESTlON OR SOMET H W TO REPORT

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