Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits

Application for Widow's or Widower's Insurance Benefits

SSA-10BK and INST

Application for Widow's or Widower's Insurance Benefits--Paper Version

OMB: 0960-0004

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0004 can be found here:

Document [pdf]

Download: pdf | pdf

SOCIAL SECURITY ADMINISTRATION

TEL

Form Approved
OMB No. 0960-0004

TOE 120/145/155

(Do not write in this space)

APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age, Survivors, and
Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the
Social Security Act, as presently amended. The information you furnish on this application will
ordinarily be sufficient for a determination on the lump-sum death payment.
*This may also be considered an application for survivors benefits under the Railroad Retirement Act
and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13
(which is, as such, an application for other types of death benefits under title 38).
If you were receiving benefits as a wife/husband at the time of your spouse's death, you need
complete only the circled items. All other claimants must complete the entire form.

1. (a) PRINT name of deceased wage earner or
self-employed person (herein
referred to as the "deceased")

Insert text "For
additional information
about this application
a fact sheet to Form
SSA-10 is available at
www.socialsecurity.
gov."

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Check (X) one for the deceased

Male

Female

(a) PRINT your name

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter your Social Security Number
(c) Enter your name at birth if different
from item 2(a)

FIRST NAME, MIDDLE INITIAL, LAST NAME

PART I -- INFORMATION ABOUT THE DECEASED
3. Enter date of birth of deceased
MONTH, DAY, YEAR
4. (a) Enter date of death

MONTH, DAY, YEAR
CITY AND STATE

(b) Enter place of death
5. Enter name of the State or foreign country where the deceased had a
fixed, permanent home at the time of death.
6. (a) Did the deceased ever file an application for Social Security
benefits, a period of disability under Social Security, supplemental
security income, or hospital or medical insurance under Medicare?
If unknown, check this block

Yes

(If "Yes," answer
(b) and (c).)

(If "No," go on
to item 7.)

(b) Enter name(s) of person(s) on whose Social
FIRST NAME, MIDDLE INITIAL, LAST NAME
Security record(s) other application was
filed.
(c) Enter Social Security Number(s) of person(s) named in (b).
If unknown, check this block

Answer Item 7 Only if the Deceased Died Prior to Full Retirement Age or Prior to 1 Year Past Full Retirement Age,
and Within the Past 4 Months.
7.
Yes
No
(a) Was the deceased unable to work because of illnesses, injuries or
(If "No," go on
(If "Yes," answer
conditions at the time of death?
to item 8.)
(b).)

(b) Enter the date the deceased became unable to work.
8. (a) Was the deceased in the active military or naval service (including
Reserve or National Guard active duty or active duty for training)
after September 7, 1939 and before 1968?
(b) Enter dates of service.

EF (01-2006)

Yes

Page 1

(If "Yes," answer
(b) and (c).)

(If "No," go on
to item 9.)

(Month, year)

FROM:

(c) Has anyone (including the deceased) received, or does anyone
expect to receive, a benefit from any other Federal agency?
Form SSA-10-BK (01-2006)
Destroy Prior Editions

MONTH, DAY, YEAR

TO:

Yes

No
(Over)

ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.
Amount
(a)
About
how
much did the deceased earn from employment and
9.
$
self-employment during the year of death?
Amount
(b) About how much did the deceased earn the year before death?
$
10. (a) Did the deceased have wages or self-employment income covered
under Social Security in all years from 1978 through last year?

Yes

(If "No," answer
(b).)

(If "Yes," skip to
item 11.)

(b) List the years from 1978 through last year in which the deceased did
not have wages or self-employment income covered under Social Security.

11. CHECK IF APPLICABLE:
I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I
understand that these earnings will be included automatically within 24 months, and any increase in my
benefits will be paid with full retroactivity.

Insert text "INFORAMTION ABOUT THE DECEASED'S MARRIAGE(S)" here

12. Enter below the information requested about each marriage of the deceased, including the marriage to you.
When (Month, Day, and Year)

Where (Enter name of City and State)

How marriage ended

When (Month, Day, and Year)

Where (Enter name of City and State)

Marriage performed by:

Spouse's date of birth

If spouse deceased, give date of death

To whom married

Last
marriage
of the
deceased

Clergyman or public official
Other (Explain in Remarks)

See addendum
for
Spouse's Social Security Number
(If none or unknown,
so indicate)
replacement text

To whom married

Previous
marriage
of the
deceased
(IF NONE,
WRITE
"NONE.")

When
(Month, Day, and Year)
for question
#12.

Where (Enter name of City and State)

How marriage ended

When (Month, Day, and Year)

Where (Enter name of City and State)

Marriage performed by:

Spouse's date of birth

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown,
so indicate)

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER PREVIOUS MARRIAGE
13. Is there a surviving parent (or parents) who was receiving support from the
Yes
No
deceased at the time of death or at the time the deceased became disabled (If "Yes," enter the name
under Social Security Law?
and address in "Remarks.")
PART II -- INFORMATION ABOUT YOURSELF
Insert text "as
14.
described in 12b"
(a) Enter name of State or foreign country where you were born.

here.
If you have already presented, or if you are now presenting, a public or religious record of your birth established
before you were age 5, go on to item 15.
(b) Was a public record of your birth made before
age 5?

Yes

Unknown

Yes

Unknown

Form SSA-10-BK (01-2006)

EF (01-2006)

Page 2

15.

Insert text "INFORMATION ABOUT YOUR MARRIAGE(S)"
Enter below information about each of your marriages. Indicate your marriage to the deceased by entering
deceased's name (if you are applying for widower's benefits, enter the maiden name of the deceased); it is not
necessary to repeat other information about this marriage you have already given in item 12. Enter complete
information on all other marriages, whether before or after you married the deceased.
To whom married

Your
current
or last
marriage

When (Month, Day, and Year)

Where (Enter name of City and State)

How marriage ended

When (Month, Day, and Year)

Where (Enter name of City and State)

Marriage performed by:

Spouse's date of birth

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown,
so indicate)

To whom married

Your
previous
marriage
(IF NONE
WRITE
"NONE")

See addendum for
replacement text
for question #15.

When (Month, Day, and Year)

Where (Enter name of City and State)

How marriage ended

When (Month, Day, and Year)

Where (Enter name of City and State)

Marriage performed by:

Spouse's date of birth

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

insert "on back of
page"

insert text "as
described in 15c"

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

USE "REMARKS" SPACE FOR INFORMATION ABOUT ANY OTHER MARRIAGE
IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17.
16.

(a) Were you and the deceased living together at the same address
when the deceased died?

Yes
(If "Yes," skip to
item 17.)

No
(If "No,"
answer (b).)

(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died,
give the following:
Who was away?
Deceased
Surviving spouse
Date last at home:

Reason absence began:

Reason you were apart at time of death:

If separated because of illness, enter nature of illness or disabling condition.

17. (a) Have you (or has someone on your behalf) ever filed an
application for Social Security benefits, a period of disability
under Social Security, supplemental security income, or hospital
or medical insurance under Medicare?
(b) Enter name of person on whose Social
Security record you filed other application

Yes

(If "Yes," answer
(b) and (c).)

(If "No," go on
to item 18.)

EF (01-2006)

Page 3

(Over)

DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19.
18.
Yes
No
(a) Are you, or during the past 14 months have you been, unable to
(If "No," go on
(If "Yes," answer
work because of illnesses, injuries or conditions?
to item 19.)
(b) .)
(Month, day, year)

(b) Enter the date you became unable to work.
19. Were you in the active military or naval service (including Reserve or
National Guard active duty or active duty for training) after
September 7, 1939 and before 1968?

Yes

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

Yes

21. (a) Did you or the deceased have Social Security credits (for
example, based on work or residence) under another country's
Social Security System?

Yes

(If "Yes,"
answer (b).)

(If "No," go on to
item 22.)

(b) If "Yes," list the country(ies).
22. (a) Have you qualified for, or do you expect to qualify for, a
pension or annuity (or a lump sum in place of a pension or
annuity) based on your own employment and earnings for the
Federal Government of the United States, or one of its States
or local subdivisions? (Social Security benefits are not
government pensions.)
(b)

I receive a government pension or annuity.
I received a lump sum in place of a government
pension or annuity.
I applied for and am awaiting a decision on my
pension or lump sum.

See addendum (New Language)
MEDICARE INFORMATION

Yes

(If "Yes," check
which of the items
in item (b) applies
to you.)

(If "No," go
on to item 23.)

I have not applied for but I expect
to begin receiving my pension or
annuity:
(Month, year)
(If the date is not known, enter "Unknown".)

MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, you will automatically receive Medicare Part
A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for
automatic enrollment in Medicare Part B, this application may be used for voluntary enrollment.
COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
In most cases, Medicare does not pay for health care you get while traveling outside the United States. Your local
Social Security Office will be glad to explain more about Medicare.
Enrollment in Medicare Part B (Medical Insurance): Medicare Part B helps cover doctor's services and outpatient care.
It also covers some other services that Medicare Part A doesn't cover. Once you are enrolled in Medicare Part B, you
will have to pay a monthly permium. The date your Medicare Part B begins and the amount of the premium you must
pay depends on the month you filed this application with the Social Security Administration. Your premiums will be
deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefit check
you receive. If you do not receive such benefits, you will be notified how to pay your premiums. You will get
advance notice if there is any change in your premium amount.
If you do not enroll in Medicare Part B now, you can enroll later only during a specified enrollment period. If you
enroll later, your coverage may be delayed and you may have to pay a higher premium.

23. Do you want to enroll in the Medicare Part B (Medical
Insurance)?
Form SSA-10-BK (01-2006)

EF (01-2006)

Page 4

Yes

ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.
24. (a) How much were your total earnings last year?

(b) Place an "X" in each block for each month of last year in which
you did not earn more than *$
in wages, and did not
perform substantial services in self-employment. These months
are exempt months. If no months were exempt months, place an
"X" in "NONE." If all months were exempt months, place an "X"
in "ALL."

NONE

*Enter the appropriate monthly limit after reading the instructions,
"How Your Earnings Affect Your Benefits."

25. (a) How much do you expect your total earnings to be this year?

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

(b) Place an "X" in each block for each month of this year in which
you did not or will not earn more than *$
in wages, and
did not or will not perform substantial services in
self-employment. These months are exempt months. If no
months are or will be exempt months, place an "X" in "NONE." If
all months are or will be exempt months, place an "X" in "ALL."

NONE

*Enter the appropriate monthly limit after reading the
instructions, "How Your Earnings Affect Your Benefits."

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

ANSWER ITEM 26 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT., OCT.,
NOV., AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR).
26. (a) How much do you expect to earn next year?

(b) Place an "X" in each block for each month of next year in which
you do not expect to earn more than *$
in wages, and
do not expect to perform substantial services in self-employment.
These months will be exempt months. If no months are expected
to be exempt months, place an "X" in "NONE." If all months are
expected to be exempt months, place an "X" in "ALL."
*Enter the appropriate monthly limit after reading
instructions, "How Your Earnings Affect Your Benefits."

27.

ALL

NONE
Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

the

If you use a fiscal year, that is, a taxable year that does not end Month
December 31 (with income tax return due April 15), enter here
the month your fiscal year ends.

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY THE
INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.
28. (a) I want benefits beginning with the earliest possible month that will be the most advantageous.

delete text

(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest
possible month that will be the most advantageous, providing that there is no permanent reduction in
my ongoing monthly benefits.
(c) I want benefits beginning with
. I understand that either a higher initial payment or a
higher continuing monthly benefit amount may be possible, but I choose not to take it.
ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.
29. Do you wish this application to be considered an application for
retirement benefits on your own earnings record?
Form SSA-10-BK (01-2006)

EF (01-2006)

Page 5

Yes

No
(Over)

Remove questions
#30 and #31.

30. Do you have any unsatisfied felony warrants for
your arrest?
31. Do you have any unsatisfied Federal or State warrants for your
arrest for violating the conditions of your probation or parole?

Yes

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)

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.
Date (Month, day, year)

SIGNATURE OF APPLICANT

Telephone number(s) at which you
may be contacted during the day

Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE

FOR
OFFICIAL
USE ONLY

Routing Transit Number

AREA CODE
Direct Deposit Payment Address (Financial Institution)
C/S Depositor Account Number
No Account
Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)
City and State

ZIP Code

Country (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature
block.
1. Signature of Witness
2. Signature of Witness
Address (Number and street, City, State and zip Code)

Form SSA-10-BK (01-2006)

EF (01-2006)

Address (Number and street, City, State and zip Code)

Page 6

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS
BEFORE YOU RECEIVE A
NOTICE OF AWARD

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING
AFTER YOU RECEIVE A
TO REPORT
NOTICE OF AWARD

In the meantime, if you change your address, or if
there is some other change that may affect your
claim, you--or someone for you--should report the
change. The changes to be reported are listed on
page 8. Always give us your claim number when
writing or telephoning about your claim.

Your application for Social Security benefits has been
received and will be processed as quickly as possible.
You should hear from us within
days after
you have given us all the information we requested.
Some claims may take longer if additional information
is needed.

CLAIMANT

If you have any questions about your claim, we will
be glad to help you.

DECEASED'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY CLAIM
NUMBER

Collection and Use of Information From Your Application - Privacy Act Notice/Paperwork Act Notice
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.

The Social Security Administration is authorized to
collect the information on this form under sections
202, 205, and 223 of the Social Security Act. The
information you provide will be used by the Social
Security Administration to determine if you or a
dependent is eligible to insurance coverage and/or
monthly benefits. You do not have to give us the
requested information. However, if you do not provide
the information, we will be unable to make an accurate
and timely decision concerning your entitlement or a
dependent's entitlement to benefit payments.

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.

The information you provide may be disclosed to
another Federal, State or local government agency for
determining eligibility for a government benefit or
program, to a Congressional office requesting
information on your behalf, to an independent party for
performance of research and statistical activities, or to
the Department of Justice for use in representing the
Federal government.

See revised
Privacy Act and
Paperwork
Reduction Act
Statements below.

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 15 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. 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-10-BK (01-2006)

EF (01-2006)

Page 7

(Over)

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES

You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)

You have an unsatisfied warrant for your arrest for
a crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment
for a term exceeding 1 year.)

Your citizenship or immigration status changes.

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

You go outside the U.S.A. for 30 consecutive days
or longer.

Disability Applicants

Any beneficiary dies or becomes unable to handle
benefits.

1. You return to work (as an employee or selfemployed) regardless of amount of earnings.

Work Changes -- On your application you told us
you expect total earnings for
to be
$
.
You
than $

(are)

2. Your condition improves.
HOW TO REPORT

(are not) earning wages of more
a month.

Insert heading Work and Earnings

You can make your reports by telephone, mail, or in
person, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.

Calling us TOLL FREE at 1-800-772-1213;
If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social Security
office shown on your claim receipt.
For general information about Social Security, visit our
web site at www.socialsecurity.gov.

(Report AT ONCE if this work pattern changes.)
Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report marriage
even if you believe that an exception applies.
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you
are confined to a public institution by court order in
connection with a crime.
Custody Change - Report if a person for whom you
are filing, or who is in your care dies, leaves your
care or custody, or changes address.
You begin to receive a government pension or
annuity (from the Federal government or any State
or any political subdivision thereof) or your pension
or annuity amount changes.

insert text "at the phone number and address"

For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount.
You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if
applicable) as the report of earnings required by law
and adjust benefits under the earnings test. It is your
responsibility to ensure that the information you give
concerning your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

Move this text under heading "Work
and Earnings" (above).

FIGURING YOUR ANNUAL EARNINGS
To figure your total yearly earnings, count all gross wages (before deductions) and net earnings from self-employment which you
earn during the entire year. This includes earnings both before and after retirement, and applies to all earned income whether or
not covered by Social Security.
In figuring your total yearly earnings, however, DO NOT COUNT ANY AMOUNTS EARNED BEGINNING WITH THE MONTH YOU
ATTAIN FULL RETIREMENT AGE. Count only amounts earned before the month you attain full retirement age.
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE ANSWERING QUESTION 28.
Benefits may be payable for some months prior to the month in which you file this claim (but not for any month before you reach
age 60 (unless you are disabled)) if:
YOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR.
(For the appropriate exempt amount, see "How Your Earnings Affect Your Benefits.")
If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually
receive your full benefit amount for one or more months before full retirement age because benefits are withheld due to your
earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at full
retirement age will be reduced only if you receive one or more full benefit payments prior to the month you attain full retirement
age.
Form SSA-10-BK (01-2006)

EF (01-2006)

Page 8

SS-10-BK, Application for Widow’s or Widower’s Insurance Benefits
PRIVACY ACT NOTICE
Collection and Use of Personal Information
Sections 202, 205 and 223 of the Social Security Act, as amended, authorize us to collect
the information requested on this form. The information you provide will be used to
make a decision on this claim. Your response is voluntary. However, failure to provide
the requested information may prevent an accurate and timely decision on any claim filed,
or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for
determining entitlement to Social Security benefits. However, in accordance with
5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided on this
form in accordance with approved routine uses which include, but are not limited to, the
following:
1. To enable an agency or third party to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer.
Computer matching programs compare our records with those of 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.
A complete list of routine uses for this information is contained in our System of Records
Notice 60-0089 (Claims Folders Systems). Additional information regarding this form
and other systems of records notices and Social Security programs are available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.

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 15
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY
OFFICE, THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. You can
find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in
your telephone directory or you may call 1-800-772-1213 (TTY 1-800-325-0778) for
the address. You may send comments on our time estimate above to: SSA, 6401
Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed report.

Form Approved OMB
No. 0960-0395

REPORTING RESPONSIBILITIES FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS 0004

List will be bullets

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE
REPAID, AND IN POSSIBLE MONETARY PENALTIES

You change your mailing address for checks or
residence. (To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.)

You begin to receive a government pension or
annuity (from the Federal government or any State
or any political subdivision thereof) or your pension
or annuity amount changes.

>Your citizenship or immigration status changes.
You have an unsatisfied warrant for your arrest for
a crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment
for a term exceeding 1 year.)

> You go outside the U.S.A. for 30 consecutive days
or longer.

>Any beneficiary dies or becomes unable to handle
benefits.
You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.
> Work Changes - On your application you told us
you expect total earnings for
to be
$
.

You |_| (are) |_| (are not) earning wages of
more
than $
a month.

Insert heading Work and Earnings
HOW TO REPORT

You can make your reports by telephone, mail, or in
person, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:

You |_| (are) |_| (are not) self-employed
rendering substantial services in your trade or
business.

> Calling us TOLL FREE at 1-800-772-1213;
+ If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or ». Calling, visiting
or writing your local Social Security
office shown on your claim receipt.

(Report AT ONCE if this work pattern changes)

For general information about Social Security, visit our
web site at www.socialsecurity.gov.

>Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report marriage
even if you believe that an exception applies.

For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount. You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if
applicable) as the report of earnings required by law
and adjust benefits under the earnings test. It is your
responsibility to ensure that the information you give
concerning your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

>Custody Change or Disability Improves - Report if a
person for whom you’re filing, or who is in your
care dies, leaves your care or custody, changes
address, or, if disabled, the condition improves.

>You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you
are confined to a public institution by court order in
connection with a crime.

insert text "at the phone number and address"

(Move highlighted paragraph to over the caption that
reads “ How to report”)

NOTICE ABOUT DOCUMENTS

We recommend that you keep all documents you submitted to us.
We are returning the documents you submitted with this claim.

Form SSA-10-INST (01-2006) EF (01-2006) Destroy prior editions

(OVER)

Collection and Use of Information From Your Application
Privacy Act Notice/Paperwork Act Notice
The Social Security Administration is authorized to collect the information on this form under sections 202, 205, and 223 of the Social
Security Act. The information you provide will be used by the Social Security Administration to determine if you or a dependent is
eligible to insurance coverage and/or monthly benefits. You do not have to give us the requested information. However, if you do not
provide the information, we will be unable to make an accurate and timely decision concerning your entitlement or a dependent's
entitlement to benefit payments.
The information you provide may be disclosed to another Federal, State or local government agency for determining eligibility for a
government benefit or program, to a Congressional office requesting information on your behalf, to an independent party for
performance of research and statistical activities, or to the Department of Justice for use in representing the Federal government.
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.

See revised Privacy Act and Paperwork
Reduction Act statements below.
Paperwork Reduction Act Notice - 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 15 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 1-800325-0778. 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-10-INST (01-2006) EF (01-2006)

File Type	application/pdf
File Title	Printing L:\LYNN'S~1\FORMFL~1\S10.FRP
Author	226490
File Modified	2009-10-05
File Created	2009-10-05