Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits

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 Personal Information
Sections 202, 205, and 233 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine eligibility of you or a
dependent for Social Security benefits.
Furnishing us this information is voluntary. However, failure to provide us with all or part of the
Information could prevent us from making an accurate and timely decision on your entitlement
or a dependent’s entitlement to Social Security benefit payments. We rarely use the information
you supply us for any purpose other than for making a determination relating to your entitlement
or a dependent’s entitlement to Social Security benefit payments. 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:
Sections 202, 205, and 233 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a decision on this claim.
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, or could result in
loss of benefits.
We rarely use the information you supply us for any purpose other than to determine entitlement
to Social Security benefits. 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 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, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census).

We may also use the information you give us 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 of this information is available in System of Records Notice
entitled, Master Beneficiary Record, 60-0090. This 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.
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, THE NEAREST U.S. EMBASSY OR
CONSULATE 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 1-800325-0778). 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.