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

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0398

TOE 210

(Do not write in this space)

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'7

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.
Choosing to receive spouse's insurance benefits before FRA will result in a permanent reduction in your monthly
benefits. Since such benefit will be at a permanently reduced rate and will continue at a permanently reduced rate
even after FRA, the law requires that we obtain a certificate of election if you wish to receive the permanently
reduced benefit. The amount of the reduction is 25/36 of 1 percent for each of the first 36 months from the start of
the permanently reduced benefits to, but not including, the month you reach FRA. The reduction is 5/12 of 1 percent
for each such month in excess of 36. 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 permanently reduced benefits as provided
in Section 202(q) of the Social Security Act, beginning with
(Year)

(Month)

4. Did you work in the railroad industry for 5 years or more?
DYes

D

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
Date (Month, day, year}

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

SIGN

Telephone Number (include area code)

HERE
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 (01-201 0) EF (01-201 0)

Destroy Prior Editions

Privacy Act Statement
See Revised Privacy Act
Statement

lection and Use of Personal Information
to collect this
e to receive

Section 202q(5)(A) of the Social Security Act ( U.S.C. 402q(5)(A)), as
information. The informa on you provide will e used to determine whe
reduced benefits as a spo e.
1sh on this form is vo untary. However, failure to provide the reque
determination regar ing payment of reduced

ion relating to
ation you supply for y purpose other than fi
approval for reduced nefits. However, we ay use it for the admini tration and integrity f Social Security
programs. We may a o disclose informatio to another person or to other agency in ace rdance with approved
routine uses, which i elude but are not limit d to the following:
1.

To ena le a third party or an a ency to assist Social Sec rity in establishing r ghts to Social Security
benefi and/or coverage;

2.

To co ply with Federal laws equiring the release ofi formation from Soc' I Security records (e.g.,
to th Government Accounta ility Office and Depart

3.

To ake determinations for ligibility in similar heal
Fed ral, state, and localleve; and

4.

To acilitate statistical resea ch and audit activities
of ocial Security program (e.g., to the Bureau of
S cia! Security).

We may also use the information you ovide in computer rna
records with ecords kept by other Fed ral, state, or local gov
programs c be used to establish or v rity a person's eligibil'
programs d for repayment of paym nts or delinquent debts

integrity and improvement
concerns under contract to

hing programs. M ching programs compare our
ment agencies. In ormation from these matching
for Federally fun d or administered benefit
nder these progra

Additiona information regarding thi form, routine uses of information, and our rograms and systems, is
available on-line at www.socialsecunty.gov or at your local Social Security offi e.

See Paperwork Reduction
Act
Paperwork Red tion Act Statement- This m ormation coli ctwn meets the requirem nts of 44 U.S.C. § 3507,
as amended by S ction 2 of the P erwork Reduction Act of 95. You do not need to nswer these questions
unless we displ a valid Office [Management and Budget ontrol number. We esti ate that it will take about 2
minutes to rea the instructions gather the facts, and answ the questions. SEND 0 BRING THE
COMPLET
FORM TO Y UR LOCAL SOCIAL
CURITY OFFICE. T office is listed under U. S.
Governmen agencies in yo telephone directory or ou may call Social Secor' y at 1-800-772-1213 (TTY
1-800-325- 78). You may end comments on our ti
estimate above to: SSA, 01 Security Blvd., Baltimore,
MD 21235 6401. Send onl comments relating too r time estimate to this addr s, not the completed form.

Form SSA-25 (01-2010) EF (01-2010)

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 205q(5)(A) of the Social Security Act (42 U.S.C. § 404), as amended, authorizes us to
collect this information. We will use the information you provide to assist us in making a
decision on your benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part ofthe
information could prevent us from making an accurate decision on your benefits.
We rarely use the information you supply for any purpose other than the reason stated above.
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, audit, or investigative 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.
A complete list of routine uses for this information is available in our System of Records Notices
entitled, Master Files of Social Security Number (SSN) Holders and SSN Applications System,
60-0058; Earnings Recording and Self Employment Income System, 60-0059; Claims Folders
Systems, 60-0089; and Master Beneficiary Record, 60-0090. These notices, additional
information regarding this form, and information regarding our systems and programs, are
available on-line at www.socialsecurity.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 (OMB) control number. We estimate that it will take about
13 minutes to read the instructions, gather the facts, and answer the questions. Send onlv
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.