Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4111 (Upload D Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits	Form	New	Available
Form SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits	Form	Modified	Available
Supporting Statement - 0759 (final).docx	Supporting Statement A	Uploaded 2026-08-27	Available
Addendum 0759.docx	Supplementary Document	Uploaded 2026-08-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
281854	Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents)	Form	New	Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
281854	Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents)	Other-Privacy Act Statement (revised)	New
180150	Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)	Form	Modified	Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
180150	Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0759	ICR Reference No: 202608-0960-005
Status: Received in OIRA	Previous ICR Reference No: 202204-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/27/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	6,787	30,000
Time Burden (Hours)	9,059	1,000
Cost Burden (Dollars)	0	0

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Abstract: To elect reduced widow(er) benefits, a recipient completes Form SSA-4111, and mails it back to SSA. SSA uses the information to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit. The respondents are qualified dually entitled widow(er)s (or surviving divorced spouse) who elect to receive a reduced widow(er) benefit.

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Authorizing Statute(s): US Code: 42 USC 402 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 38753	06/26/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 55418	08/27/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)	SSA-4111	Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents)	SSA-4111 (Upload Documents)	Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,787	30,000	0	521	-23,734	0
Annual Time Burden (Hours)	9,059	1,000	0	287	7,772	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2023, the burden was 1,000 hours. However, we are currently reporting a burden of 1,471 hours. The increase in burden is due to SSA erroneously adding an extra zero (i.e., 30,000 instead of 3,000) in the last clearance. The increase also stems from an increase of completion time from 2 minutes to 13 minutes. These figures represent current Management Information data. *Note: The total burden reflected in ROCIS is 9,059, while the burden cited in #12 of the Supporting Statement is 1,471. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + telephone call system wait times + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $134,270

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/27/2026

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