Form SSA-2 Application for Wife's or Husband's Insurance Benefits

Form Approved
OMB No 0960-0618

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.
“APPLICATION
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-

Employed Person
(Herein referred to as the "Worker")

FIRST NAME, MIDDLE INITIAL, LAST NAME
X

(b) Enter Worker's Social Security Number
2.

-

X

Check (X) whether you are

Male

X

3.

-

Female

FIRST NAME, MIDDLE INITIAL, LAST NAME
X

(a) PRINT your name

-

X

(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.
4.5. Enter the language you prefer to:

Speak

Write

5.6. (a) Enter your date of birth

X

(b) Enter name of city,
or foreign
country
city State
and state,
or foreign
country
where you were born

MONTH, DAY, YEAR

X

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

X
X

Yes

No

Unknown

Yes

No

Unknown

6.7.

Yes
X

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

(If "Yes," go
7).
to item 8.)

Yes (Go to item (c))

X

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

7)
No (Go to item 8)

(c) When were you lawfully admitted to the U.S.?
7.8.

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

FIRST NAME,

MIDDLE INITIAL,

X

Yes

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

(c) Other name(s) used.

X

No
(If "No," go to
Item 8).
9.)

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

X

8.9. (a) Have you used any other Social Security Number(s)
If "Yes,"
what
number(s)
did you
use?
(b) Enter
Social
Security
number(s)
used.
Form SSA-2-BK (12-2010) ef (12-2010)

LAST NAME

Yes
X

(Go to item
(b))

Page 1

No
(Go to item
9.)

9 IF YOU ARE ONE YEAR PAST FULL RETIREMENT AGE OR OLDER.
DO NOT ANSWER QUESTION 10
10.
GO ON TO QUESTION 11.

10.
9.

(a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?
X
If “Yes” when do you believe your condition(s) became

(b) Ifsevere
"Yes",enough
enter the
dateyou
you
became
work.
to keep
from
workingunable
(even iftoyou

No
(If "No," go to
item 11.)
10).
YEAR

X

have never worked)?

11.
10.

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

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

X

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

No

FIRST NAME,

(If "No," go to
item 12.)
11).

MIDDLE INITIAL,

LAST NAME

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

12. (a) Were you in the active military or naval service (including
11.
Reserve or National Guard active duty or active duty for
training) after September 7, 1939 and before 1968?

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

X

No
(If "No," go to
item 13.)
12).
(MONTH, YEAR)

(MONTH, YEAR)
(b) Enter date(s) of service

X

(c) Have
everbeen
been(or(or
eligible
for monthly
Have you
you ever
willwill
youyou
be)be
eligible
for monthly
benefit from
fromaamilitary
military
civilian
Federal
agency?)
benefits
or or
civilian
Federal
agency
(Include
Veterans
Administration
benefits only if you
waived
Military
(including
Veterans Administration
benefits
only
if you
retirement
pay)? retirement pay)
waived Military

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

(b) List the other country (ies).
15.
14.

To:
Yes

No

Yes

No

Yes

No

X

13. Did you, or your spouse, (or prior spouse) work in the railroad
12.
industry for 5 years or more?
13.
14.

From:

X

X

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

(If "No," go to
item 15.)
14).

X

(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.)
15).
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.

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

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

I agree
to promptly
the Social
Administration
I become
entitledan
to a
I agree
to promptly
notifynotify
the Social
SecuritySecurity
Administration
if I become ifentitled
to a pension,
annuity,
or a or
lump
sum payment
my employment
coveredby
bySocial
Social Security,
if my
pension
annuity
based based
on myonemployment
notnot
covered
Security,oror
if
pension or annuity amount changes
or
stops.
such pension or annuity stops.
Form SSA-2-BK (12-2010) ef (12-2010)

Page 2

enter the
16. (a) Enter information about your marriage to the worker. If you married the worker more than once, use the 'Remarks' space to endter
15.
15(b) if you are filing as a divorced spouse; otherwise, go to item 16(c)
additional marriage information. Go to item 16(b)
15(c)

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

Spouse's name (including maiden name)

Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security Number (If none or unknown, so indicate)
(b) If you remarried after the divorce from the worker, enter the marriage information. If you did not remarry, write "None"
15(c) if you had other marriages.
Go on to item 16(c)

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

Spouse's name (including maiden name)

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

(c) Enter information about any marriage if you:
•Had a marriage that lasted at least 10 years; or
•Had a marriage that ended due to the death of your spouse, regardless of duration; or
•Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the combined
enter the additional marriage information. Do no repeat
period of marriage totaled 10 years or more .Use the "Remarks" space to ender
15(a) or 16(b).
15(b). If none, write "None". _________
any marriages listed in item 16(a)
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

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
17.
16. If you are more than one year past full retirement age, go to question 18.
question 17.

Form SSA-2-BK (12-2010) ef (10-2010)

Page 3

17. Has an unmarried child of the worker (including adopted child, or stepchild) or a
16.

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")

17.
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
21.
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?

X

19. (a) How much were your total earnings last year?
18.

Yes

No

NONE

ALL

X $

(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".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings
Affect
YourYour
Benefits".
“How Work
Affects
Benefits.”
20. (a) How much do you expect your total earnings to be this year?
19.

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

X$

(b) 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".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings
Affect
YourYour
Benefits".
“How Work
Affects
Benefits.”

NONE

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).
X $

21. (a) How much do you expect to earn next year?
20.
(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
YourYour
Benefits".
“How Work
Affects
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.
X
Month

Form SSA-2-BK (12-2010) ef (12-2010)

Page 4

21. If
If you are now under full retirement age and do not have an entitled child in your care, answer item 22.
22.
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.
21.

X

(a) I want benefits beginning with the earliest possible month and will accept an age related reduction.
(b) I am full retirement age (or will be within 12 months) and want benefits beginning with the earliest possible
month providing there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with

.

X
X

MEDICARE INFORMATION
IfIfthis
approved
andand
youyou
are are
still stilll
entitled
to benefits
at ageat
65,
or you
are within
3 months of age
65 orMedicare
older you Part
couldA
thisclaim
claimis is
approved
entitled
to benefits
age
65, you
will automatically
receive
automatically
receive
Medicare
Part
A
(Hospital
Insurance)
and
Medicare
Part
B
(Medical
Insurance)
coverage
at
age
65.
If you live in
(Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic
Puerto
Rico
or
a
foreign
country,
you
are
not
eligible
for
automatic
enrollment
in
Medicare
Part
B,
and
you
will
need
to
contact
Social
enrollment in Medicare Part B, this application may be used for voluntary enrollment.
Security to request enrollment.

22 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
COMPLETE ITEM 23
Medicare
Part
B (Medical
Insurance)
helpsdoctor's
cover doctor's
and outpatient
also covers
some that
other
services
Medicare
Part
B (Medical
Insurance)
helps cover
services services
and outpatient
care. It also care.
coversIt some
other services
Medicare
thatA Medicare
Part such
A doesn't
cover,
such
as some
of theand
services
of physical
andand
occupational
some
home
Part
does not cover,
as some
of the
services
of physical
occupational
therapists
some hometherapists
health care.and
If you
enroll
in
health care.
If you
youwill
enroll
Part premium.
B, you will
have
to pay
a monthly
The amount
your
premium
will be
Medicare
Part B,
haveintoMedicare
pay a monthly
The
amount
of your
premiumpremium.
will be determined
whenof
your
coverage
begins.
In
some
cases, your
premium
may be higher
based
information
income
we be
receive
from
the Internal
Revenue Service.
Your
determined
when
your coverage
begins.
Inon
some
cases,about
your your
premium
may
higher
based
on information
about your
premiums
will be
deducted
monthly
Social Security,
Retirement,will
or be
Office
of Personnel
receive.
income we
receive
fromfrom
theany
Internal
Revenue
Service.Railroad
Your premiums
deducted
from Management
any monthlybenefits
Social you
Security,
If Railroad
you do notRetirement,
receive any of
you will Management
get a letter explaining
how
to pay
your premiums.
You receive
will also any
get aofletter
if there
is any
orthese
Officebenefits,
of Personnel
benefits
you
receive.
If you do not
these
benefits,
change
in the
your premium.
you will
get amount
a letterofexplaining
how to pay your premiums. You will also get a letter if there is any change in the amount of
You
canpremium.
also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you
your
can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare can also tell you about
You canin also
in a
Medicare
drug plan (Part
D). To learn
about
Medicare
agencies
your enroll
area that
can
help you prescription
choose your prescription
drug coverage.
The more
amount
of your
premiumprescription
varies based drug
on theplans and
when youdrug
can plan
enroll
visit www.medicare.gov
prescription
provider.
The amount you payor
forcall
Part1-800-MEDICARE
D coverage may be (1-800-633-4227;
higher than the listedTTY
plan1-877-486-2048).
premium, based on Medicare
information
about
receive
from theinInternal
Revenue
can your
also income
tell youwe
about
agencies
your area
that Service.
can help you choose your prescription drug coverage.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare
If you have
limited
and
resources,
wemonthly
encourage
you toannual
applydeductibles,
for the Extra
that is available
to assist
you
withor
prescription
drug
costs.income
The Extra
Help
can pay the
premiums,
andHelp
prescription
co-payments.
To learn
more
apply,
pleaseprescription
visit www.socialsecurity.gov,
1-800-772-1213
(TTY
or visitannual
the nearest
Social Security
office.
Medicare
drug costs. Thecall
Extra
Help can pay
the1-800-325-0778)
monthly premiums,
deductibles,
and prescription
co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0078) or
visit the nearest Social Security office.
23. Do you want to enroll
22.
in Medicare Part B (Medical Insurance)?

X

23.
24. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for Supplemental
Security Income?
X

Yes

No

Yes

No

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

Form SSA-2-BK (12-2010) ef (12-2010)

Page 5

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
oror
gives false
a false
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
Telephone number(s) at which you may
be contacted during the day

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

SIGN X
HERE

Direct Deposit Payment Address (Financial Institution)

FOR
OFFICIAL
USE ONLY

Routing Transit Number

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)

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Form SSA-2-BK (12-2010) ef (12-2010)

Page 6

Routing
Transit
Number

Account Number

Checking

Enroll in Direct Express

Savings

Direct Deposit Refused

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

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

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

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

WORKER'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY NUMBER

Collection and Use of Information From Your Application—Privacy Act Notice/Paperwork Reduction Act Notice
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide to determine if you or a dependent are eligible for insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent us from
making an accurate and timely decision concerning your or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than 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 right 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,
investigative,
and
audit
activities
necessary to assure
the integrity of Social
See Revised
Privacy
Act
and
PRA Statements
Attached
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.
Additional information regarding this form, routine uses of information, and our programs and systems, is available online 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 11 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 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-2-BK (12-2010) ef (12-2010)

Page 7

 Your
stepchild is
CHANGES TO BE REPORTED AND HOW TO REPORT
entitled to
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN
benefits on
POSSIBLE MONETARY PENALTIES
your
X You change your mailing address for checks or
X Custody Change or Disability Improves — Report if a record, and
you and the
residence. ( To avoid delay in receipt of checks you
person for whom you are filing, or who is in your care stepchild's
should ALSO file a regular change of address notice
dies, leaves your care or custody, changes address, parent
with your post office.)
divorce.
or if disabled, the condition improves.
X Your citizenship or immigration status changes.
Stepchild

X If you become the parent of a child (including an

X Any beneficiary goes outside the U.S.A. for 30

consecutive days or longer.

adopted child) after you have filed your claim, let us
know about the child so we can decide if the child is
eligible for benefits. Failure to report the existence of
these children may result in the loss of possible
benefits to the child(ren).

X Any beneficiary dies or becomes unable to handle

benefits
X Work Changes -- On your application you told us you

expect total earnings for
$
.
You
than $

(are)

to be

(Year)

HOW TO REPORT
online,
by telephone,
You can make your reports by
telephone,
mail, ormail,
in or in
person, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:

(are not) earning wages of more
a month

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.

“my Social
Security”
Visiting the section "What
you can
do online"
at our web site at www.socialsecurity.gov;
Calling us TOLL FREE at 1-800-772-1213;
If you are deaf or hearing impaired, calling us
TOLL FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social Security
office at the phone number and address shown on
your claim receipt.
For general information about Social Security, visit our
web site at www.socialsecurity.gov.
For those under full retirement age, the law requires that a
report of earnings be filed with SSA within 3 months and
15 days after the end of any taxable year in which you
earn more than the annual exempt amount. You may
contact SSA to file a report. Otherwise, SSA will use the
earnings reported by your employer(s) and your
self-employment tax return (if applicable) as the report of
earnings required by law and adjust benefits under the
earnings test. It is your responsibility to ensure that the
information you give concerning your earnings is correct.
You must furnish additional information as needed when
your benefit adjustment is not correct based on the
earnings on your record.

(Report AT ONCE if this work pattern changes)
X Change of Marital Status — Marriage, divorce, and

annulment of marriage. You must report marriage
even if you believe that an exception applies.
You are confined to a jail, prison, penal institution or
X You are confined to jail, prison, penal institution or
correctional facility for more than 30 continuous days for
correctional
conviction
of a crime
or you
conviction of afacility
crime,for
or you
are confined
for more
than are
30
confined
a public
institution
by court
in in
continuoustodays
to a public
institution
by a order
court order
connection
witha acrime.
crime.
connection with
You have
have an
unsatisfied warrant
warrant for
for more
more than
30 continuous
continuous days
You
unsatisfied
30
X You
haveanan
unsatisfied
warrant
forthan
your
arrest for days
a
for your
your arrest
arrest for
for aa crime
crime or
or attempted
attempted crime
crime that
that is
is aa felony
felony of
of
for

crime
attempted
crime
that is a felony
flight to
toor
avoid
prosecution
or confinement,
confinement,
escape(or,
fromin
custody
flight
avoid
prosecution
or
escape
from
custody
jurisdictions
thatIn
notjurisdictions
define crimes
a
and flight-escape.
flight-escape.
Indo
most
jurisdictions
that do
doas
notfelonies,
classify crimes
crimes
and
most
that
not
classify
as felonies,
felonies,
applies
a crime
thatby
is or
punishable
by death for
orfor
as
that to
is punishable
death
or imprisonment
crime
that athis
iscrime
punishable
by death
imprisonment
for aone
term
exceeding
oneofyear
of the
term exceeding
(regardless
the (regardless
actual sentence
aaimprisonment
term
exceeding
1year
year.)
X

benefits are
not payable
beginning
with the
month after
the month
the divorce
becomes
final.

actual sentence imposed).
imposed).

You
havean
anunsatisfied
unsatisfied
warrant
a violation
You have
warrant
for for
more
than 30 of
probation
parole
Federal
or State
law. under
continuousor
days
for aunder
violation
of probation
or parole

Federal
or State
law. to a pension or annuity based
X You
become
entitled
on
your
employment
coveredan
byannuity,
Social or
Security,
You
become
entitled tonot
a pension,
a lump
payment
based
your employment
covered by
orsum
if such
pension
oron
annuity
changes ornot
stops.
Social Security, or if such pension or annuity stops.

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
21.
BEFORE YOU ANSWER QUESTION 22.
X If you are under full retirement age, wife's or husband's benefits cannot be paid for any month before the month in

which you file your claim.

X If you are full retirement age or older, wife's or husband's benefits may be payable for some months before the month

in which you file this claim, but not before the month you attain full retirement age.
X 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 (12-2010) ef (12-2010)

Page 8

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine if you or a dependent are
eligible for insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, if you fail to provide all or part
of the requested information it may prevent us from making an accurate and timely decision
concerning your or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than determining benefit
payments for you or a dependent. However, we may use it for the administration and integrity of
our 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 us in establishing right 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 of Social Security programs. (e.g., to the Bureau of 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. 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 incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of
Records Notices entitled, Earnings Recording and Self Employment Income System (60-0059)
and Claims Folders Systems (60-0089). Additional information regarding these and other
systems of records notices, 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 15 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 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to our time
estimate to this address, not the completed form.