Current Version of the SSA-2

Form Approved
OMB No 0960-0008

TOE 120/145/155

TEL

SOCIAL SECURITY ADMINISTRATION

(Do not write in this space)

APPLICATION FOR WIFE'S OR HUSBAND'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.
Supplement. If you have already completed an application entitled "APPLICATION FOR RETIREMENT INSURANCE BENEFITS", you need complete only the
circled items. All other claimants must complete the entire form.
1. (a) PRINT Name of Wage Earner or Self-

FIRST NAME, MIDDLE INITIAL, LAST NAME

Employed Person
(Herein referred to as the "Worker")
(b) Enter Worker's Social Security number
2.

Male

Check (X) whether you are

3.

-

Female

FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name

-

(b) Enter your Social Security number

-

4. If this claim is awarded, do you want a password to use SSA's Internet/phone service?

Yes

No

Answer question 5 if English is not your preferred language. Otherwise go to item 6.
5. Enter the language you prefer to:
6.

Speak

Write
MONTH, DAY, YEAR

(a) Enter your date of birth
(b) Enter name of city, State or foreign country
where you were born
(c) Was a public record of your birth made before you
were age 5?

Yes

No

Unknown

(d) Was a religious record of your birth made before you
were age 5?

Yes

No

Unknown

7.

Yes

(a) Are you a U.S. citizen?
Yes

(b) Are you an alien lawfully present in U.S.?
8.

(a) Enter your full name at birth
if different from item 3(a)

No

FIRST NAME,

MIDDLE INITIAL,

LAST NAME

No

Yes

(b) Have you used any other name(s)?

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

(If "Yes," go
to item 8.)

(If "No," go to
Item 9.)

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

(c) Other name(s) used.
9. (a) Have you used any other Social Security number(s)

Yes

If "Yes," what number(s) did you use?

Form SSA-2-BK (4-2006) ef (4-2006)

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No

DO NOT ANSWER QUESTION 10 IF YOU ARE ONE YEAR PAST FULL RETIREMENT AGE OR OLDER.
GO ON TO QUESTION 11.
10. (a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?

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

No
(If "No," go to
item 11.)
YEAR

(b) If "Yes", enter the date you became unable to work.

11.
(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?

Yes

No

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

(b) Enter name of person(s) on whose Social Security record
you filed other application.

FIRST NAME,

(If "No," go to
item 12.)

MIDDLE INITIAL,

LAST NAME

(c) Enter Social Security number(s) of person named in (b).
(If unknown, so indicate)

Answer item 12, if you have been in the military service. Otherwise, go to item 13.
Yes
(If "Yes," answer
(b) and (c).)

12. (a) 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?

No
(If "No," go to
item 13.)

(MONTH, YEAR)

(MONTH, YEAR)

(b) Enter date(s) of service
From:
(c) Have you ever been (or will you be eligible for monthly
benefit from a military or civilian Federal agency?) (including
Veterans Administration benefits only if you waived
Military retirement pay)

13. Did you, or your spouse, (or prior spouse) work in the railroad
industry for 5 years or more?

14. (a) Do you have Social Security credits (for example,
based on work or residence) under another country's
Social Security system?

To:
Yes

No

Yes

No

Yes

No

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

(If "No," go to
item 15.)

(b) List the country(ies):
15.

(a) Are you entitled to, or do you expect to be entitled to a pension or
annuity (or a lump sum in place of a pension or annuity) based on
your own employment and earnings from the Federal government
of the United States, or one of its States or local subdivisions?
(Social Security benefits are not government pensions.)

Yes

No

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

(b) Check one box and provide the date in (c)

(If "No," go
on to item 16.)

YEAR

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.
I have not applied for but I expect to begin receiving my pension or annuity.

Form SSA-2-BK (4-2006) ef (4-2006)

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(If the date is not known,
enter "Unknown".)

16. Enter below the information requested about each of your marriages. Include information on your marriage to the

worker and any other marriages, whether before or after you married the worker.
When (Month, day, year)

Where (Name of City and State)

How marriage ended (If still in
effect, write "Not Ended.")

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

Your
current
or last
marriage

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

When (Month, day, year)

Where (Name of City and State)

How marriage ended

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

Your
previous
marriage
(If none write
"NONE".)

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

(Use "Remarks" space on page 5 for information about any other marriages.)
If you are now under full retirement age or less than one year past full retirement age, answer
question 17. If you are more than one year past full retirement age, go to question 18.
17. Has an unmarried child of the worker (including natural child, adopted
child, or stepchild) or a dependent grandchild of the worker (including
stepgrandchild) who is under 16 or disabled lived with you during any
of the last 13 months (counting the present month)?
(If "Yes," enter the information requested below.)

Name of child

Yes

No

Months child lived with you (if all, write "All")

18. (a) Enter below the names and addresses of all the persons, companies, or government agencies for whom you have worked this
year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO THE INSTRUCTIONS FOR
ITEM 22.
NAME AND ADDRESS OF EMPLOYER
(If you had more than one employer, please list them
in order beginning with your last (most recent) employer).

Work Began
Month

Year

Work Ended
(If still working,
Show "Not Ended")
Month
Year

(If you need more space, use "Remarks")
(b) Are you an officer of a corporation, or are you related to an officer of a
corporation?
Form SSA-2-BK (4-2006) ef (4-2006)

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Yes

No

19. (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".
20. (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.

$

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 this item 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).
21. (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".

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.

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

If you are now under full retirement age and do not have an entitled child in your care, answer item 22.
If you are full retirement age or older or you have an entitled child in your care, go to item 23.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF THE FOLLOWING
ITEMS.
22.

(a) I want benefits beginning with the earliest possible month that will be the most advantageous.
(b) I am full retirement age (or will be full retirement age within 4 months) and I want benefits beginning with the earliest possible
month that will be the most advantageous, providing 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.

MEDICARE INFORMATION
If this claim is approved and you are stilll 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.

Form SSA-2-BK (4-2006) ef (4-2006)

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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 premium. 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 Medicare Part B (Medical Insurance)?

Yes

No

24. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for Supplemental
Security Income?

Yes

No

25. Do you have any unsatisfied felony warrants for your arrest?

Yes

No

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

Yes

No

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

Form SSA-2-BK (4-2006) ef (4-2006)

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REMARKS (con't.)

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 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 face other penalties, or both.
Date (Month, day, year)

SIGNATURE OF APPLICANT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)

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

SIGN
HERE

FOR
OFFICIAL
USE ONLY

Routing Transit Number

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

County (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 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)

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

Form SSA-2-BK (4-2006) ef (4-2006)

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

TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING TO REPORT

(

)

SSA OFFICE

DATE CLAIM RECEIVED

-

AFTER YOU RECEIVE A
NOTICE OF AWARD

(

)

or if there is some other change that may affect your
claim, you—or someone for you—should report the
change to the telephone number shown above. 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.

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

In the meantime, if you have a change of address,
CLAIMANT

WORKER'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY NUMBER

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 12.5 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. 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.
Collection and Use of Information From Your Application—Privacy Act Notice/Paperwork Reduction Act Notice
The Social Security Administration is authorized to collect the information requested 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.
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.

Form SSA-2-BK (4-2006) ef (4-2006)

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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 have an unsatisfied warrant for a violation of
You change your mailing address for checks or
probation or parole under Federal or State law.
residence. (To avoid delay in receipt of checks
you should ALSO file a regular change of
Custody Change or Disability Improves — Report if
address notice with your post office.)
a person for whom you are filing, or who is in your
Your citizenship or immigration status changes.
care dies, leaves your care or custody, changes
address, or if disabled, the condition improves.
Any beneficiary goes outside the U.S.A. for 30
consecutive days or longer.
You begin to receive a government pension or your
pension (from the Federal government or any State
Any beneficiary dies or becomes unable to handle
benefits.
or any political subdivision thereof) or your pension
or annuity amount changes.
Work Changes -- On your application you told us you
to be
expect total earnings for
HOW TO REPORT
(Year)
$
.
You can make your reports by telephone, mail, or in
person, whichever you prefer.
You
(are)
(are not) earning wages of more
than $
a month.
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
Calling us TOLL FREE at 1-800-772-1213;
substantial services in your trade or business.
If you are deaf or hearing impaired, calling us
(Report AT ONCE if this work pattern changes)
TOLL FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social Security
Change of Marital Status — Marriage, divorce, and
office at the phone number and address shown on
annulment of marriage. You must report marriage
your claim receipt.
even if you believe that an exception applies.
For general information about Social Security, visit our
web site at www.socialsecurity.gov.
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you are
For those under full retirement age, the law requires that
a report of earnings be filed with SSA within 3 months
confined to a public institution by court order in
and 15 days after the end of any taxable year in which
connection with a crime.
you earn more than the annual exempt amount. You
may contact SSA to file a report. Otherwise, SSA will
You have an unsatisfied warrant for your arrest for a
use the earnings reported by your employer(s) and your
crime or attempted crime that is a felony (or, in
self-employment tax return (if applicable) as the report
jurisdictions that do not define crimes as felonies, a
of earnings required by law and adjust benefits under
crime that is punishable by death or imprisonment
the earnings test. It is your responsibility to ensure that
the information you give concerning your earnings is
for a term exceeding 1 year.)
correct. You must furnish additional information as
needed when your benefit adjustment is not correct
based on the earnings on your record.
Under a special rule known as the Monthly Earnings Test, you can get a full benefit for any month in which you do not earn
wages over the monthly limit and do not perform substantial services in self-employment regardless of how much you earn
in the year. For retirement age beneficiaries this special rule can be used only for one taxable year which will usually be the
year of retirement. For younger beneficiaries such as young wives and husbands (entitled only by reason of child-in-care),
this special rule can be used for two taxable years. The first taxable year in which the monthly earnings test may be used is
usually the first year they are entitled to benefits. The second taxable year in which the monthly earnings test can be used is
always the year in which their entitlement to benefits stops. In all other years, the total amount of benefits payable will be
based solely on your total yearly earnings without regard to monthly earnings or services rendered in self-employment.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
BEFORE YOU ANSWER QUESTION 22.
Benefits may be payable for some months prior to the month in which you file this claim (but not for any month before
the first month you will be age 62 for the entire month) 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-2-BK (4-2006) ef (4-2006)

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