Current Version of the SSA-2

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.
Supplement. If you have already completed an application entitled "APPLICA- TION
FOR RETIREMENT INSURANCE BENEFITS", you need complete only the circled
items. All other claimants must complete the entire form.

FIRST NAME, MIDDLE INITIAL, LAST NAME

1. (a) PRINT Name of Wage Earner or Self-

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

u

(b) Enter Worker's Social Security Number
2.
3.

Check (X) whether you are

Male

u
u

(a) PRINT your name

-

u

-

Female

FIRST NAME, MIDDLE INITIAL, LAST NAME

-

u

(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

(a) Enter your date of birth

u

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

u

(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?

u
u

MONTH, DAY, YEAR

Yes

No

Unknown

Yes

No

Unknown

7.

Yes

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

u

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

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

Yes (Go to item (c))

u

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

No (Go to item 8)

(c) When were you lawfully admitted to the U.S.?
8.

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

FIRST NAME,

MIDDLE INITIAL,

u

Yes

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

(c) Other name(s) used.

u

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

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

u

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

LAST NAME

Yes
u
Page 1

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

11.

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

YEAR

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

u

(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).)

u

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

No

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)
u
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?

u
u

(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)

From:

To:
Yes

No

Yes

No

Yes

No

u

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

u

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

15.

(MONTH, YEAR)

(MONTH, YEAR)

(b) Enter date(s) of service

(b) List the other country (ies).

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

u

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

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

u

(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.

(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 notify the Social Security Administration if I become entitled to a
pension or annuity based on my employment not covered by Social Security, or if
such pension or annuity stops.
Form SSA-2-BK (12-2010) ef (12-2010)

Page 2

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

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
period of marriage totaled 10 years or more Use the "Remarks" space to ender the additional marriage information. Do no repeat
any marriages listed in item 16(a) or 16(b). If none, write "None". _________
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
question 17. If you are more than one year past full retirement age, go to question 18.

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

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?

u

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

Yes

No

NONE

ALL

u $

(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 Your Benefits".
20. (a) How much do you expect your total earnings to be this year?

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

u$

(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 Your 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).
u $

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.
u
Month

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

Page 4

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 and will accept an age related reduction.

u

(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.

u

(c) I want benefits beginning with

.

u

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.
COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services
that Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home
health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be
determined when your coverage begins. In some cases, your premium may be higher based on information about your
income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security,
Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits,
you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of
your premium.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about Medicare prescription drug plans and
when you 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 agencies in your area that 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 prescription drug costs. The Extra Help can pay the monthly premiums, annual 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
in Medicare Part B (Medical Insurance)?

u

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

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 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

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

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

SIGN u
HERE

FOR
OFFICIAL
USE ONLY

Direct Deposit Payment Address (Financial Institution)
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)

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

Page 6

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

To facilitate statistical research, investigative, and audit activities necessary to assure the integrity of Social
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.
4.

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

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

u 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).

u Any beneficiary dies or becomes unable to handle

benefits

u Work Changes -- On your application you told us you

expect total earnings for
$
.

You
than $

(are)

to be

HOW TO REPORT
You can make your reports by telephone, mail, 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:

(Year)

(are not) earning wages of more
a month

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

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)
u Change of Marital Status — Marriage, divorce, and

annulment of marriage. You must report marriage
even if you believe that an exception applies.

u You are confined to jail, prison, penal institution or

correctional facility for conviction of a crime or you are
confined to a public institution by court order in
connection with a crime.

u You have an unsatisfied warrant for your arrest for a

crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment for
a term exceeding 1 year.)

u

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

u You become entitled to a pension or annuity based

on your employment not covered by Social Security,
or if such pension or annuity changes or 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
BEFORE YOU ANSWER QUESTION 22.
u 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.

u 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.

u 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