Form SSA-753 Statement Regarding Marriage

Form SSA-753 (03-2018) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION

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OMB No. 0960-0017

STATEMENT REGARDING MARRIAGE
All questions must be answered or marked "Unknown." If you need more space for answers, continue them under "Remarks" on
reverse side.
Enter Worker's Social Security
Print Name of Wage Earner or Self-Employed Person (Herein referred to as the "Worker".)
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
a married couple?
5.

Did (do) you consider them married couple?

Yes

No

Yes

No

Yes

No

Give facts and explain fully the reasons for your belief:

6.

Did you hear them refer to each other as a spouse?
If "Yes," when and where?

Form SSA-753 (03-2018) UF
7. In your opinion, did (do) they maintain a home and live together as a married couple?
If ''Yes,'' where and when?
CITY OR TOWN

STATE

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No

Yes

FROM

DATES

TO

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

Yes

No

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.

Yes

No

STATE WHETHER
WORKER OR
APPLICANT

TO WHOM MARRIED

DATE AND PLACE OF HOW MARRIAGE
MARRIAGE
TERMINATED

DATE AND PLACE
MARRIAGE
TERMINATED

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

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 (include Area Code)
Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)
City and State

ZIP Code

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 (03-2018) UF

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Privacy Act Statement
Collection and Use of Personal Information

Section 216(h)(1)(A) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on the
individual’s claim.

See Revised Privacy Act Statement Attached

We will use the information you provide to establish an individual’s marital relationship and to make an eligibility determination for
Social Security benefits. We may also share the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of
its programs; and,
2. To student volunteers, individuals working under a personal services contract, and other workers who technically do not
have the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access
to personally identifiable information in SSA records in order to perform their assigned Agency functions.
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 (SORNs) 60-0089, entitled Claims
Folders Systems and 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information and a full listing of all our
SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
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
See Revised PRA Attached
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.