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

TEL

SOCIAL SECURITY ADMINISTRATION

TOE 120/145/155

APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS

Form Approved
OMB No 0960-0618
(Do not write in this space)

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

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter Worker's Social Security Number
Female

Male

2. Check (X) whether you are
3.

FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name
(b) Enter your Social Security Number
Answer question 4 if English is not your preferred language. Otherwise go to item 5.

4. Enter the language you prefer to:
5.

Write

Speak

MONTH, DAY, YEAR

(a) Enter your date of birth

(b) Enter name of city and state, or foreign country where you were born
(c) Was a public record of your birth made before you were age 5?

Yes

No

Unknown

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

Yes

No

Unknown

6.
(a) Are you a U.S. citizen?

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

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

Yes (Go to item (c))

No (Go to item 7)

(b) Are you an alien lawfully present in U.S.?
(c) When were you lawfully admitted to the U.S.?
7. (a) Enter your full name at birth if different from
item 3(a)

FIRST NAME, MIDDLE INITIAL, LAST NAME

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

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

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

(c) Other name(s) used.
8.

(a) Have you used any other Social Security number(s)?
(b) Enter Social Security number(s) used.

Form SSA-2-BK (02-2014) ef (02-2014)
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Yes

No

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

(a) Are you, or during the past 14 months have you been,
unable to work because of illnesses, injuries or conditions?
(b) If “Yes” when do you believe your condition(s) became
severe enough to keep you from working (even if you have
never worked)?

10. (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?

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

No

Yes

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

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

Yes
No
(If "Yes," answer (b) (If "No," go to item 11.)
and (c).)

FIRST NAME, MIDDLE INITIAL, LAST NAME

(c) Enter Social Security Number(s) of person named in
(b). (If unknown, so indicate)
11. (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?

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

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

(b) Enter date(s) of service
From:
(c) Have you ever been (or will you be) eligible for monthly
benefits from a military or civilian Federal agency (Include
Veterans Administration benefits only if you waived Military
retirement pay)?
12. Did you, or your spouse, (or prior spouse) work in the railroad
industry for 5 years or more?
13. (a) Do you have Social Security credits (for example, based on
work or residence) under another country's Social Security
system?

To:

Yes

No

Yes

No

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

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

(b) List the other country (ies).
14. (a) Are you entitled to, or do you expect to be entitled to a
Yes
pension or annuity (or a lump sum in place of a pension or
annuity) based on your own employment and earnings from (If "Yes," check which
of the items in item (b)
the Federal government of the United States, or one of its
States or local subdivisions? (Social Security benefits are not applies to you.)
government pensions.)
(b) Check one box and provide the date in (c)

(c) MONTH

No
(If "No," go on to
item 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.
I have not applied for but I expect to begin receiving my pension
or annuity.

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

I agree to promptly notify the Social Security Administration if I become
entitled to a pension, an annuity, or a lump sum payment based on my
employment not covered by Social Security, or if my pension or annuity
amount changes or stops.
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15. (a) Enter information about your marriage to the worker. If you married the worker more than once, use the
'Remarks' space to enter the additional marriage information. Go to item 15(b) if you are filing as a divorced
spouse; otherwise, go to item 15(c)
Spouse's name (including maiden name) When (Month, day, year)
Where (Name of City and State)

How marriage ended (If still in effect,
write "Not Ended.")
Marriage performed by:
Clergyman or public official
Other (Explain in "Remarks")

When (Month, day, year)
Spouse's date of birth (or age)

Where (Name of City and State)
If spouse deceased, give date of death

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 15(c) if you had other marriages.
Spouse's name (including maiden name) When (Month, day, year)
Where (Name of City and State)
How marriage ended
Marriage performed by:

When (Month, day, year)
Spouse's date of birth (or age)

Where (Name of City and State)
If spouse deceased, give date of death

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 enter the additional
marriage information. Do not repeat any marriages listed in item 16(a) or 16(b). If none, write "None". _________
To whom married
When (Month, day, year)
Where (Name of City and State)
How marriage ended
Marriage performed by:
Clergyman or public official

When (Month, day, year)
Spouse's date of birth (or age)

Where (Name of City and State)
If spouse deceased, give date of death

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

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16. 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")

17. 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 21.
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")
$

18. (a) How much were your total earnings last year?
(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 inself-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 Work Affects Your Benefits".
19. (a) How much do you expect your total earnings to be this year?
(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 Work Affects Your Benefits".

NONE

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

$
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).
$
20. (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".
*Enter the appropriate monthly limit after reading the instructions,
"How Work Affects Your Benefits".

NONE

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.
Month
Form SSA-2-BK (02-2014) ef (02-2014)

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If you are now under full retirement age and do not have an entitled child in your care, answer item 21. If you
are full retirement age or older or you have an entitled child in your care, go to item 22.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF
THE FOLLOWING ITEMS.
21. (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

.

MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you
could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at
age 65. If you live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B,
and you will need to contact Social Security to request enrollment.
COMPLETE ITEM 22 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 does not 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 the 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. The amount of your premium varies based on the prescription drug plan provider. The amount you pay
for Part D coverage may be higher than the listed plan premium, based on information about your income we receive
from the Internal Revenue Service.
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
1-800-325-0778) or visit the nearest Social Security office.
22. Do you want to enroll in Medicare Part B (Medical Insurance)?

Yes

No

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

Yes

No

23.

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
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Form SSA-2-BK (02-2014) ef (02-2014)

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REMARKS (con't.)
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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 a 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)

Direct Deposit Payment Information (Financial Institution)
Routing Transit Number

Account Number

Checking

Enroll in Direct Express

Savings

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)

Form SSA-2-BK (02-2014) ef (02-2014)

Address (Number and Street, City, State and ZIP Code)

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RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIFE'S OR HUSBAND'S INSURANCE BENEFITS
BEFORE YOU RECEIVE
A NOTICE OF AWARD
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING TO REPORT

DATE CLAIM RECEIVED

AFTER YOU RECEIVE A
NOTICE OF AWARD

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

SSA OFFICE

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.

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, 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 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.
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Form SSA-2-BK (02-2014) ef (02-2014)

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CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE
MONETARY PENALTIES
Custody Change or Disability Improves - Report if a
You change your mailing address for checks or
person for whom you are filing, or who is in your care
residence. (To avoid delay in receipt of checks you
dies, leaves your care or custody, changes address,
should ALSO file a regular change of address notice with
or if disabled, the condition improves.
your post office.)
Your citizenship or immigration status changes.
If you become the parent of a child (including an
adopted child) after you have filed your claim, let us
Any beneficiary goes outside the U.S.A. for 30
know about the child so we can decide if the child is
consecutive days or longer.
eligible for benefits. Failure to report the existence of
Any beneficiary dies or becomes unable to handle
these children may result in the loss of possible
benefits
benefits to the child(ren).
Work Changes - On your application you told us you
Your stepchild is entitled to benefits on your record
expect total earnings for
to be
and you and the stepchild's parent divorce. Stepchild
(Year)
$
.
benefits are not payable beginning with the month
after the month the divorce becomes final.
You
(are)
(are not) earning wages of more
HOW TO REPORT
than $
a month
You can make your reports online, by telephone,
You
(are)
(are not) self-employed rendering
mail, or in person, whichever you prefer.
substantial services in your trade or business.
If you are awarded benefits, and one or more of the
(Report AT ONCE if this work pattern changes)
above change(s) occur, you should report by:
Change of Marital Status - Marriage, divorce, and
• Visiting the section “my Social Security” at our web
annulment of marriage. You must report marriage even
site at www.socialsecurity.gov;
if you believe that an exception applies.
• Calling us TOLL FREE at 1-800-772-1213;
• If you are deaf or hearing impaired, calling us TOLL
You are confined to a jail, prison, penal institution or
FREE at TTY 1-800-325-0778; or
correctional facility for more than 30 continuous days
• Calling, visiting or writing your local Social Security
for conviction of a crime, or you are confined for
office at the phone number and address shown on
more than 30 continuous days to a public institution
your claim receipt.
by a court order in connection with a crime.
You have an unsatisfied warrant for more than 30
For general information about Social Security, visit
continuous days for your arrest for a crime or
our web site at www.socialsecurity.gov.
attempted crime that is a felony of flight to avoid
For
those under full retirement age, the law requires
prosecution or confinement, escape from custody
that
a report of earnings be filed with SSA within 3
and flight-escape. In most jurisdictions that do not
months and 15 days after the end of any taxable year
classify crimes as felonies, this applies to a crime
in which you earn more than the annual exempt
that is punishable by death or imprisonment for a
amount. You may contact SSA to file a report.
term exceeding one year (regardless of the actual
Otherwise, SSA will use the earnings reported by
sentence imposed).
your employer(s) and your self-employment tax
You have an unsatisfied warrant for more than 30
return (if applicable) as the report of earnings
continuous days for a violation of probation or parole
required by law and adjust benefits under the
under Federal or State law.
earnings test. It is your responsibility to ensure that
You become entitled to a pension, an annuity, or a
the information you give concerning your earnings is
lump sum payment based on your employment not
correct. You must furnish additional information as
covered by Social Security, or if such pension or
needed when your benefit adjustment is not correct
annuity stops.
based on the earnings on your record.

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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 selfemployment.
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU ANSWER QUESTION 21.
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.
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.
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.
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Form SSA-2-BK (02-2014) ef (02-2014)

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