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

SSA-10-BK - Revised Items
 Page 2, Question 11, updated language:
I am not submitting evidence of the deceased’s earnings that are not yet on his/her
earnings record. I understand that these earnings will be included automatically
within 24 months, and any increase in my benefits will be paid with full
retroactivity.

Page 7 of 8

Form SSA-10 (06-2017) UF

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

SSA OFFICE

DATE CLAIM RECEIVED

AFTER YOU RECEIVE A
NOTICE OF AWARD

Your appl1cat1on for Social Security benefits has been received
and will be processed as quickly as possible.

In the meantime, 1f you change your address, or if there is some
other change that may affect your claim, you - or someone for
you - should report the change. The changes to be reported are
You should hear from us within __ days after you have given listed on page 8. Always give us your claim number when
us all the information we requested. Some claims may take
writing or telephoning about your claim.
longer if additional information is needed.
If you have any questions about your claim, we will be glad to
help you.
CLAIMANT

DECEASED'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY CLAIM
NUMBER

See Revised Privacy
PRIVACY ACT� STA,£..v-,\.EAJT
Collection and Use of Personal Information Statement Attached

Act

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 qr a dependent for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may 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:
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 the information you provided us is available in our 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 (0MB) control number. The 0MB control number for this collection is 0960-0004. We estimate that it
will take about 15 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.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(e) and 202(f) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide us with all
or part of the information could prevent us from making an accurate and timely decision on your
entitlement for widow or widower benefits.
We will use the information to make a determination for entitlement to widow or widower
benefits. We may also share your information for the following purposes, called routine uses:


To contractors and other Federal agencies, as necessary, for assisting Social Security
Administration (SSA) in the efficient administration of its programs. We contemplate
disclosing information under this routine use only in situations in which SSA may enter a
contractual or similar agreement, with a third party to assist in accomplishing an agency
function relating to this system of records; and



To third party contacts, especially in situations where the party to be contacted has, or is
expected to have, information relating to the individual’s capability to manage his/her
affairs or his/her eligibility for or entitlement to benefits under the Social Security
program; when the data are needed to establish the validity of evidence; to verify the
accuracy of information presented by the individual and, if it concerns his/her eligibility
for benefits under the Social Security program.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 60-0090 entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of all our
SORNs, is available on our website at www.ssa.gov/privacy.