Form SSA-754-F5 Statement of Marital Relationship

Form SSA-754-F5 (12-2019) UF
Discontinue Prior Editions
Social Security Administration

STATEMENT OF MARITAL RELATIONSHIP (By one of the parties)

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OMB No. 0960-0038
(Do not write in this space)

All items on this form requiring an answer must be answered or marked "Unknown."
I understand that the information given by me will be used in connection with an application filed for
insurance benefits payable under Title II of the Social Security Act, as amended, based on the
earnings of the wage earner or self-employed person named below.
1. Print name of wage earner or self employed person
2. Print your full name (First, middle initial, last)
4. When did you begin living
together as spouses?
Month
Year

Social Security Number
3. Name of person with whom you were living:

Where did you live?
City or Town

State

5. A. Did you live together continuously since that time?

Yes

No

If "No," give the periods of separation and the reasons why you did not live together.

B. Where have you lived together as spouses and for what periods of time?
City or Town

State

Dates
To

From

6. Did you and the person you were living with have an understanding about your relationship
Yes
when you began living together?
A. If it was in writing, furnish a copy; if it was not in writing, what did you say to each other about your living together?

B. Was this understanding later changed?
If "yes", what were the changes and why were they made?

7. Did you and the person you were living with have an understanding about how long you would
live together?
If "yes", what did you say to each other about how long you would live together?

8. A. Did you have an understanding as to how your relationship could be ended?

No

Yes

No

Yes

No

Yes

No

Yes

No

B. If "Yes" what did you say to each other on this subject?

9. A. Did you believe that your living together made you legally married?
B. If "Yes" why did you believe so?

Form SSA-754-F5 (12-2019) UF
10. A. Was there an agreement or promise that a ceremonial marriage would also be performed
in the future?
B. If "Yes" explain why the ceremony was not performed.

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Yes

No

11. A. Were any children born of this relationship?

Yes

No

B. If "Yes," list below:
Date of Birth
(or Age)

Full Name at Birth

Place of Birth

12. By what names were you and the person with whom you were living known?
A. Your name before you lived together

B. The person's name before you lived together

C. Your name since you lived together

D. The person's name since you lived together

E. If you both did not use the same last name after you began living together, state the reasons.

13. A. After you started living together, were there any tax returns filed, deeds or contracts
executed, insurance policies taken out, bank accounts opened up, etc.?

Yes

No

B. If "Yes", give the following information:
Type of Document

Date Made Out

Were You Shown as
the Other's Spouse?

14. A. Did you have joint business dealings with other persons or joint charge accounts in stores?

Yes

No

Yes

No

Yes

No

Yes

No

B. If "Yes", give the names and address of such persons or stores:
Name of Person or Store

Address

Date of
Transaction

15 A. How did you introduce the person with whom you were living to relatives, friends, neighbors, business acquaintances and
others?

B. How did that person introduce you to relatives, friends, neighbors, business acquaintances and others?

16. How was mail addressed to you and the other person with whom you were living with?

Form SSA-754-F5 (12-2019) UF

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17. List below the names of your and the other person's employers and neighbors who knew of your relationship:

18. List below your closest relatives (other than children) who knew of your relationship?
Name

Address

Relationship

19. List below the closest relatives of the person with whom you were living (other than children) who knew of your relationship:
Name

Address

Relationship

20. One or more of the employers and/or relatives shown above may be contacted regarding knowledge they may have of your
marriage. If you object to our contacting any of the above, please list the name(s) and give the reason(s) for your objection(s).

Yes

21. A. Did you ever live with any other person as spouses?

No

B. If "Yes", give the following information:
Dates

Kind of Relationship
(Ceremonial, etc.)

Name of Person

How Relationship
Ended

22. A. Did the person named in item 3 ever live with anyone else as spouses?

Date and Place
Relationship Ended

Yes

No

B. If "Yes", give the following information:
Dates

Kind of Relationship
(Ceremonial, etc.)

Name of Person

How Relationship
Ended

Date and Place
Relationship Ended

Form SSA-754-F5 (12-2019) UF
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ANSWER ITEM 23 IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT WAS STILL
IN EFFECT AT THE TIME YOU BEGAN LIVING TOGETHER.
23. A. Did you at the time you began living together know that the earlier marriage was still in effect?

Yes

No

If "No," answer (B) and (C):
B. When and how did you find out that this marriage was still in effect?

C. When and how did the person with whom you were living first learn that this marriage was still in effect?

ANSWER ITEM 24 ONLY IF EITHER OF YOU HAD AN EARLIER CEREMONIAL OR COMMON-LAW MARRIAGE THAT
ENDED AFTER YOU BEGAN LIVING TOGETHER.
24. A. When and how did you first learn that this marriage had ended?

B. When and how did the person with whom you were living first learn that this marriage had ended?

C. After both of you learned that the earlier marriage had ended, did you say anything to each other
about your relationship?
If "Yes" what did you say to each other?

25. REMARKS:

Yes

No

Form SSA-754-F5 (12-2019) UF

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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 may face other penalties, or both.
Signature of Applicant (First name, middle initial, last name)

Date (MM/DD/YYYY)
Telephone number at which you may be called
during the day (including area code)

Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)

City
State

County (if any in which you now live)

ZIP Code

Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
2. Signature of Witness
1. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)

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

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act &
PRA Statements attached

Section 216(h), 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 us from making an accurate and timely decision on
any claim filed.
We will use the information to determine your eligibility for benefits. We may also share your information for the following
purposes, called routine uses:
1. To Federal, State or local agencies for administering cash or non-cash income maintenance or health maintenance
programs; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration in the efficient administration of its programs.
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 Folder
Systems, and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available
on our website at www.ssa.gov/privacy/sorn.html.
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 (OMB)
control number. We estimate that it will take about 30 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.