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

REPORTING RESPONSIBILITIES FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN
POSSIBLE MONETARY PENALTIES

You change your mailing address for checks or
residence. To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.
Your citizenship or immigration status changes.
Any beneficiary goes outside the U.S.A. for 30
consecutive days or longer.
Any beneficiary dies or becomes unable to handle
benefits.
Work Changes — On your application you told us
you expect total earnings for
to be
Year
$
.
You
than $

(are)

(are not) earning wages of more
a month.

You
(are)
(are not) self-employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes)
Change of Marital Status — Marriage, divorce,
annulment of marriage. You must report marriage
even if you believe that an exception applies.

Custody Change or Disability Improves — Report if a
person for whom you are filing, or who is in your
care dies, leaves your care or custody, changes
address, or, if disabled, the condition improves.
Ź Your stepchild is entitled to benefits on your record and you and the
stepchild's parent divorce. Stepchild benefits are not payable beginning
with the month after the month the divorce becomes final.

You
areconfined
confined
jail,
prison,
penal
institution
or
You are
to atojail,
prison,
penal
institution
or
correctional
facility
for than
conviction
of a days
crime
correctional facility
for more
30 continuous
foror
confined
toa acrime,
public
institution
by for
court
conviction of
or you
are confined
more order
than 30in
connection with a crime.
continuous days to a public institution by a court order in
connection with a crime.

FORM SSA -2 -INST (04 -2006 ) (EF 04 -2006 ) Destroy prior editions

You
an
unsatisfied
warrant
for
continuous
You have
have
anan
unsatisfied
warrantwarrant
for more
more than
than
30
continuous
days
for
You
have
unsatisfied
for 30
your
arrestdays
for for
a
your
arrest
for
aa crime
or
attempted
crime
that
is
aa felony
of
flight
to
your
arrest
for
crime
or
attempted
crime
that
is
felony
of
flight
to
crime or attempted crime that is a felony (or, in
avoid
avoid prosecution
prosecution or
or confinement,
confinement, escape
escape from
from custody
custody and
and flightflightjurisdictions
that
do not define
crimes
as felonies,
a
escape.
escape. In
In most
most jurisdictions
jurisdictions that
that do
do not
not classify
classify crimes
crimes as
as felonies,
felonies, a
crime
that
is
punishable
by
death
or
imprisonment
this
applies
a crime that
punishable
by death or
for
crime
that istopunishable
byisdeath
or imprisonment
forimprisonment
a term
for
a term
exceeding
1 year.)
aexceeding
term
exceeding
one(regardless
year (regardless
of the actual
sentence
one year
of the actual
sentence
imposed).

You have
warrant
for more
30 continuous
You
haveananunsatisfied
unsatisfied
warrant
forthan
a violation
of
probation
or parole
under Federal
or under
StateFederal
law. or
days for a violation
of probation
or parole
State law.

You
begin to receive a government pension or
You begin to receive a government pension, or annuity, or you
annuity (from the Federal government or any State
receive a lump sum payment (from the Federal government or
or
any political subdivision thereof) or your pension
anyannuity
State oramount
any political
subdivision thereof) not covered by
or
changes.
Social Security, or your pension or annuity amount changes or
HOW
stops. TO REPORT
online,
by telephone,
You can make your reports by
telephone,
mail,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:
i Calling us TOLL FREE at 1-800-772-1213;
i

If you are deaf or hearing impaired, calling us
TOLL FREE at TTY 1-800-325-0778; or
i Calling, visiting or writing your local Social
Security office at the phone number and
address shown on your claim receipt.
Ź
For general information about Social Security, Visiting
the
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, to 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.

Page 1

section
“my
Social
Security”
at our
web site
at
www.soci
alsecurity
.gov.

NOTICE ABOUT DOCUMENTS
copies
of all documents
you submitted
to us.
We recommend that you keep all
documents
you submitted
to us.

We are returning the documents you submitted with this claim.

Collection and Use of Information From Your Application Privacy Act Notice/Paperwork Reduction Act Notice
The Social Security Administration is authorized to collect the information requested on this form
under sections 202, 205 and 223 of the Social Security Act. The information you provide will be
used by the Social Security Administration to determine if you or a dependent is eligible to insurance
coverage and/or monthly benefits. You do not have to give us the requested information. However,
if you do not provide the information, we will be unable to make an accurate and timely decision
concerning your entitlement or a dependent's entitlement to benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency
for determining eligibility for a government benefit or program, to a Congressional office requesting
information on your behalf, to an independent party for the performance of research and statistical
activities, or to the Department of Justice for use in representing the Federal government.
We may also use this information when we match records by computer. Matching programs compare
our records with those of other Federal, State, or local government agencies. Many agencies may
use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
See Revised Privacy Act and PRA Statements Attached
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 12.5 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. 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-INST (04-2006 ) (EF 04- 2006 ) Destroy prior editions

Page 2

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Collection and Use of Personal Information
Privacy Act Statement
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 is
eligible to 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, we will be unable to make an accurate and timely decision
concerning your entitlement or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than for determining continuing
eligibility. 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 rights to our benefits
and 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 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 matching 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 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.