Form SSA-753 Statement Regarding Marriage

SOCIAL SECURITY ADMINISTRATION

TOE 420

STATEMENT REGARDING MARRIAGE

Form Approved
OMB NO. 0960-0017

All questions must be answered or marked "Unknown." If you need more space for answers, continue them under "Remarks"
on reverse side.

See Revised Privacy Act
Statement and PRA

Privacy Act Statement Statement Regarding Marriage: Section 216(h)(1)(A) [42 U.S.C. 216(h)(1)(A)] of the Social Security Act, as amended, authorizes us to
collect this information. We will use the information you provide to help establish the applicant’s eligibility to Social Security benefits. The information you provide
is voluntary. However, failure to provide the requested information could prevent us from establishing if a marital relationship exists and from making an accurate
and timely decision on the applicant’s claim. We rarely use the information provided on this form for any purpose other than for the reasons stated above. However,
we may use it for the administration and integrity of Social Security programs. We may also disclose the information provided on this form in accordance with
approved routine uses of the Privacy Act (5 U.S.C. § 552a), 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 our
records (e.g., to the Government Accountability Office, General Services Administration, National Archives Records Administration, and the 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.
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
Systems of Records Notice entitled, Claims Folder System, 60-0089; and Electronic Disability (eDIB) Claim File, 60-0320. These notices, 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.
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 9
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.

Print Name of Wage Earner or Self-Employed Person
(Herein referred to as the "Worker".)

Enter His (Her) Social Security Number

Print Name of Applicant

I understand that this statement will be considered in connection with an application by the applicant named
above for payment of benefits under the provisions of Title II of the Social Security Act, as amended, based on
the earnings of the Worker named above.
Print Your Full Name (First name, middle initial, last name)

1. What is your relationship to the Worker? (Mother, child, cousin, etc. — if not related, state "None.")
To the Applicant? (Mother, child, cousin, etc. — if not related, state "None.")
2. How long have you known the Worker?

The Applicant?

3. How often and on what occasions did you meet the Worker?

The Applicant?

4. To your knowledge, were (are) the Worker and Applicant generally known as
husband and wife?
5. Did (do) you consider them husband and wife?

Yes

No

Yes

No

Give facts and explain fully the reasons for your belief:

Form SSA-753 (11-2011) EF (11-2011)

(Over)

6. Did you hear them refer to each as husband and wife?

Yes

No

Yes

No

If "Yes," when and where?

7. In your opinion, did (do) they maintain a home and live together as husband and wife?
If ''Yes,'' where and when?

CITY OR TOWN

DATES

STATE

FROM—

TO—

8. To your knowledge, did they live together continuously?
If "No," explain.

9. To your knowledge, has either the Worker or the Applicant entered into any other marriage?
If ''Yes, '' give the following information regarding all such marriages.
STATE WHETHER WORKER
OR APPLICANT

TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

HOW MARRIAGE
TERMINATED

Yes

No

Yes

No

DATE AND PLACE
MARRIAGE TERMINATED

(This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

Remarks:

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 MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number

SIGN
HERE

X

Area Code

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)

ZIP Code

City and State

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the person making the statement 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-753 (11-2011) EF (11-2011)

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 216(h)(1)(A) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to establish an individual’s marital
relationship and to make an eligibility determination for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0089, entitled, Claims Folders
Systems; and, 60-0320, entitled, Electronic Disability (eDIB) Claim File. Additional
information about these and other system of records notices and our programs are available
online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through 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.

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 9
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.