Form SSA-25 (original)

Form Approved
OMB No. 0960-0398
(Do not write in this space)

SOCIAL SECURITY ADMINISTRATION

TOE 210

CERTIFICATE OF ELECTION
FOR REDUCED SPOUSE'S BENEFITS
Paperwork/Privacy Act Notice: The authority for collecting the information requested on
this form is contained in section 202q(5)(A) of the Social Security Act (42 U.S.C.
402q(5)(A)). Submission of the information requested is voluntary. The purpose for which
the information is requested is to determine whether the spouse may be eligible to receive
reduced benefits. Failure to provide any or all of the requested information will prevent
payment of reduced benefits. Information you furnish on this form may be disclosed by
the Social Security Administration to another person or governmental agency only with
respect to Social Security programs and to comply with Federal laws requiring the
exchange of information between the Social Security Administration and another agency.

ENTER HIS OR HER SOCIAL SECURITY NUMBER

1. PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
(Hereafter called ''Worker'')

2. PRINT YOUR FULL NAME (First name, middle initial, last name)

ENTER YOUR SOCIAL SECURITY NUMBER
(If "none" or "unknown" so indicate.)

A spouse's insurance benefit may be payable for months between age 62 and full retirement age (FRA), even if you
do not have in your care a child of the worker under age 16 or disabled entitled to a child's insurance benefit.
However, since such benefit will be at a reduced rate and will continue at a reduced rate even after FRA, the law
requires that we obtain a certificate of election if you wish to receive the reduced benefit. The amount of the
reduction is 25/36 of 1 percent times the number of months from the start of the reduced benefits to, but not
including, the month you reach FRA. In addition, if another beneficiary(ies) other than the wage earner (e.g., a student
child beneficiary) is entitled to a monthly benefit on this Social Security number, election for a reduced spouse's
benefit may cause a reduction in total monthly benefits. These reduced benefits may be paid for as many as 12
months before the month this certificate is filed. No reduced spouse's benefit may begin before the month you are
62. If you are eligible for retirement insurance benefits in the month this certificate takes effect, you will be
considered to have applied for them.
3. I elect to accept reduced benefits as provided in
Section 202(q) of the Social Security Act, beginning with
(Month)

(Year)

4. Were you in the active military or naval service after September 7, 1939 and before 1968?
Yes

No

5. Did you work in the railroad industry for 5 years or more?
Yes

No

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.
SIGNATURE OF PERSON COMPLETING THIS CERTIFICATE
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

SIGN
HERE

Telephone Number (include area code)

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

ZIP Code

Enter Name of County (if any) in which you now live

Witnesses are required ONLY if this certificate has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the person completing this certificate 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-25 (6-2004) EF (06-2004)

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 2 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 estimate to this
address, not the completed form.

Form SSA-25 (6-2004) EF (06-2004)