Form SSA-25 Certificate of Elections for Reduced Spouse's Benefits

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

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 (02-2006) EF (02-2006)

See attached
revised language
Privacy Act Notice: The Social Security Administration is authorized to collect the
information requested on this form under Section 202q(5)(A) of the Social
Security Act (42 U.S.C 402q(5)(A)). The information requested on the form will be
used to determine whether you may be eligible to receive reduced benefits as a
spouse. You do not have to give us this information. However, without the
information, we will be unable to determine if you are entitled to payment of
reduced benefits.
The information you provide may be disclosed to the Office of the President or to
a congressional office requesting information on your behalf, to the General
Services Administration and the National Archives and Records Administration for
conducting records management studies, and to contractors and other Federal
agencies, as necessary, to assist in the administration of Social Security
Administration programs.
We may also use this information 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 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.

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, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form SSA-25 (02-2006) EF (02-2006)

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 202q(5)(A) of the Social Security Act (42 U.S.C. 402q(5)(A)), as amended,
authorizes us to collect this information. The information you provide will be used to
determine whether you may be eligible to receive reduced benefits as a spouse.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent us from making a determination regarding payment of
reduced benefits.
We rarely use the information you supply for any purpose other than for making a
determination relating to approval for reduced benefits. 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.socialsecurity.gov or at your local
Social Security office.