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 ISSA) is authorized to collect the information on this form under section 216Ih)(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. SSA 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. While the information you furnish on this form would almost never be used for any purpose other than the intended
use of this form, such information may be disclosed by SSA as generally permitted under 5 U.S.C. § 552alb) of the Privacy Act of 1974, as amended. This
includes using the information as necessary for administrative purposes or as authorized by routine uses in the applicable Privacy Act system of records.
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 possible reasons why information you provide us may be used or provided to other agencies are available upon request from any Social
Security Office.

See Revised Privacy Act and PRA Statements 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 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-S00-772-1213ITTY 1-S00-325-077S). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send

rm!Y. comments relating to our time estimate to this address, not the completed form.

Print Name of Wage Earner or Self-Employed Person

Enter His (Her) Social Security Number

(Herein referred to as the "Worker".)

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 Agglicant? (Mother, child, cousin, etc. - if not related, state "None. ")

2. How long have you known the Worker?

IThe Agglicant?

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

The Agglicant?

4, To your knowledge, were (are) the Worker and Applicant generally known as
husband and wife?

D

Yes

D

No

5. Did (do) you consider them husband and wife?

D

Yes

D

No

Give facts and explain fully the reasons for your belief:

Form SSA-753 (3-2009) EF (3-2009)

(Over)

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

Yes

D

No

Yes

D

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

B.

DATES

STATE

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

TO­

FROM­

HOW MARRIAGE
TERMINATED

Yes

D

No

Yes

D

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.
SIGNATURE OF PERSON MAKING STATEMENT
Date (Month, day, year)

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

Telephone Number

SiGN . . . .

HERE

Area Code

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

City and State

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark IX), 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 (3-2009) EF (3-2009)

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Privacy Act Statement
Statement Regarding Marriage
Section 216(h)(1)(A) [42 U.S.C. 216(h)(1)(A)] of the Social Security Act, as amended,
authorizes us to collect this information. We will use the information you provide to help
establish the applicant’s eligibility to Social Security benefits. The information you
provide is voluntary. However, failure to provide the requested information could
prevent us from establishing if a marital relationship exists and from making an accurate
and timely decision on the applicant’s claim.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose the information provided on this form
in accordance with approved routine uses of the Privacy Act (5 U.S.C. § 552a), 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 our
records (e.g., to the Government Accountability Office, General Services
Administration, National Archives Records, Administration, and the 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, audit, or investigative activities necessary to
assure the integrity of Social Security programs.

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.
A complete list of routine uses for this information is available in Systems of Records
Notice entitled, Claims Folder System, 60-0089; and Electronic Disability (eDIB)
Claim File, 60-0320. These notices, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local 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 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. 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 Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.