Form SSA-4111 Certificate of Election for Reduced Widow(er)?s Benefits

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0759

CERTIFICATE OF ELECTION FOR REDUCED WIDOW(ER)'S AND
SURVIVING DIVORCED SPOUSE'S BENEFITS
1. PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
(Hereafter called "Worker")

ENTER HIS OR HER SOCIAL SECURITY NUMBER

2. PRINT YOUR FULL NAME (First name, middle initial, last name)

ENTER YOUR SOCIAL SECURITY NUMBER
(If "none" or "unknown" so indicate.)

INFORMATION ABOUT REDUCED WIDOW(ER)'S AND
SURVIVING DIVORCED SPOUSE'S BENEFITS
The law requires that you complete and return this Certificate of Election if you wish to receive a reduced widow's,
widower's or surviving divorced spouse's benefit and are at least age 62 and under full retirement age (FRA).
The following will affect the amount of your benefit:





The month and year you elect to begin to receive benefits will determine the amount of your monthly
payments which will continue at a reduced rate even after you reach FRA.
Depending on your date of birth, the rate of reduction applied to your benefit amount can range
from 19/40 to 19/56 of 1 percent times the number of months from the start of the reduced
benefits until the month you reach FRA.
If another beneficiary is entitled to a monthly survivor benefit on this Social Security number, your
benefit may be reduced by the total family benefit payable in the month. The benefit paid to a surviving
divorced spouse will not affect the benefit amount paid to other family members who receive benefits on the
same record.

INFORMATION ON HOW BENEFITS ARE AFFECTED IF THE DECEASED WORKER RECEIVED REDUCED RETIREMENT
BENEFITS
If the deceased worker received retirement benefits before FRA, the maximum survivor's benefit is limited to the higher
amount that the deceased worker would have received if still alive or 82.5 percent of the deceased worker's unreduced
benefit. Because of this limit, delaying receipt of reduced benefits will not necessarily increase the monthly benefit
amount payable. We will review your election in item 3 below to make sure that the month selected maximizes your
benefit amount.
3. I elect to accept permanently reduced benefits as provided in Section MONTH
202(q) of the Social Security Act, beginning with

YEAR

Enter any month beginning with the month of the deceased worker's death up
to, but not including the month you reach FRA provided that the month you
choose is within the past 12 months.

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

Date (Month, day, year)

SIGN
HERE

Telephone Number (include area code)

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-4111 (07-2009) EF (07-2009)
Destroy Prior Editions

(over)

Privacy Act Statement

See Revised PAS

Sections 202(e), (f) and (q)(3) (42 U.S.C. 402) of the Social Security Act , as amended, authorizes us
to collect this information. The information you provide is used to determine whether you may be
eligible to receive reduced benefits as a widow(er) or a surviving divorced spouse. Your response is
voluntary. However, failure to provide all or part of the requested information could prevent an
accurate and timely decision on this claim.
We rarely use this information provided on this form for any other purpose other than for the reasons
explained 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 General Accounting Office and Department of Veteran's Affairs);
3. To make determinations for eligibity 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 ensure the
integrity and improvement of Social Security programs.
We may also use this information you provided 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 and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice
60-0089. The notice, 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.

See Revised Paperwork Reduction Act Statement
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 2 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
form.

Form SSA-4111 (07-2009) EF (07-2009)
Destroy Prior Editions

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

Sections 202(e), (f), and (q)(3) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to determine your eligibility for
reduced benefits as a widow(er) or a surviving divorced spouse.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent an accurate and timely decision on this claim.
We rarely use the information you supply for any purpose other than to determine your eligibility
for reduced benefits. However, we may use the information for the efficient administration of
our programs. We may also disclose information to another person or agency in accordance with
approved routine uses, including but 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 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 our programs (e.g., to the Bureau of the Census and
to 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 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 Privacy Act System of
Records Notice entitled, Claims Folders Systems, 60-0089. Additional information about this
and other system of records notices and our programs are available from our Internet website at
www.socialsecurity.gov or at your 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 2
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.