Form SSA-3 Marriage Certification

TOE 1201420

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMS No. 0960·0009

SEE PAPERWORK/PRIVACY
ACT NOTICE ON REVERSE.

MARRIAGE CERTIFICATION
PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

I am the spouse of the person named below, who has applied for insurance benefits under Title II of the Social Security Act, as
presentf~ amended.
NAME OF SPOUSE (First Name)

(Maiden Name, if applicable)

(Last Name)

1. Indicate whether your present marriage was performed by:

o

o

Clergyman or Authorized Public Official

2. Were you married before your present
marria\ie?

~

Other (Explain)

DYes

(If "yes", give the following information
.
.)
abouteach0 f your preVIous
marriages.

TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY;

SPOUSE'S DATE OF BIRTH (or age)

GIVE DATE OF DEATH IF SPOUSE IS
DECEASED

P M
R A
E R
V R
I I
o A
U G
S E

[ ] Clergyman or Public Official
Other (Explain in "REMARKS")

o

Spouse's Social Security Number

(If none or unknown, so indicate)

11---- I - - I

~-.

----

TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY:

SPOUSE'S DATE OF BIRTH (or age)

GIVE DATE OF DEATH IF SPOUSE IS
DECEASED

P M
R A
E R
V R
I I
OA
U G
S E

0
0

Clergyman or Public Official
Other (Explain in "REMARKS")

Spouse's Social Security Number

(If none .or unknown, so indicate)

li-

-- I -- / ----

REMARKS: (Use this space and the reverse of this form for information about any other previous marriages, if necessary)

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.
SIGNATURE OF WAGE EARNER OR SELF-EMPLOYED PERSON
DATE (Month, Day, Year)
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)

SIGN

TELEPHONE NUMBER (Area Code)

HERE
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, or Rural Route)

Witnesses are required ONLY if this statement has been signed by mark: (Xl above. If signed by mark: (X), two witnesses to the
signing who know the wage earner or self-employed person must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA-3 (11-2009) EF (11-2009) Destroy Prior Editions

2. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State and ZIP Code)

Reverse

See below for revised Paperwork
Reduction Act and Privacy Act
Statements.

Privacy Act Statement

Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this infonnation. The
infonnation you provide will be used to determine the identity of your spouse.
The information you furnish on this fonn is voluntary. However, failure to provide the requested
information may prevent us from paying benefits to your spouse.
We rarely use the infonnation you supply for any purpose other than for detennining the identity of a
spouse. 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 infonnation from Social Security records (e.g.,
to the Government Accountability Office and Department of Veterans' Affairs);
3. To make detenninations 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 infonnation regarding this form, routine uses of infonnation, and our programs and systems,
is available on-line at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This infonnation collection meets the requirements of 44 U.S.c.
§ 3507, as amended by Section 2 of the Paperwork &duction Act of.l225. 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 5 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 1-800-325-0778). 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/orm.

Form SSA·3 (11-2009) EF (11-2009)

Marriage Certification SSA-3
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, [42 U.S.C. 405(a)] authorizes us
to collect this information. We will use the information you provide to help us determine
the identity of your spouse. The information you furnish on this form is voluntary.
However, failure to provide the requested information may prevent us from paying
benefits to your spouse.
We rarely use the information you supply for any purpose other than for determining the
identity of a spouse. 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 entities under contract with us).
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. We use the information from these matching programs to establish
or verify a person’s eligibility for Federally-funded or administered benefit programs and
for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled Claims Folders Systems, 60-0089 and Master Beneficiary Record 600090. The notices, additional information regarding this form, and information regarding
our systems and programs, are available on-line at www.ssa.gov or at any local Social
Security office.

SSA will insert the following revised PRA Statement 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 5
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.