Title of Information Collection and Form Number(s)

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Supporting Statement for Form SSA-4111
Certificate of Election for Reduced Widow(er)’s and
Surviving Divorced Spouse’s Benefits
20 CFR 404.335
OMB No. 0960-0759

A. 	Justification

    1. Introduction/Authoring Laws and Regulations
Sections 202(e)(1)(C)(ii)(III) and 202(f)(1)(C)(ii)(III) of the Social Security Act (Act), and 20 CFR 404.335-404.336 of the Code of Federal Regulations, set forth the eligibility criteria and dates for a widow(er) or surviving divorced spouse to file a Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits.  Section 202(q) of the Act allows SSA to reduce benefits if a Title II beneficiary chooses to receive them early.  However, we will not pay reduced benefits to a spouse or divorced spouse for any month before they officially request reduced benefits, or for any month when they are caring for a child who is entitled to child’s insurance benefits based on the insured person’s record.

    2. Description of Collection
A claimant may be eligible to benefits as the widow(er), surviving divorced spouse, or disabled widow(er) based on the earnings of a deceased number holder (NH).  To qualify for monthly benefits, SSA requires the claimant to:
    • Attain age 60, or if disabled, attain age 50 but not age 60);
    • Meet the marriage requirement;
    • Have a child with the deceased NH;
    • Not qualify for a retirement benefit on their own retirement benefit which equals or exceeds the deceased primary insurance amount; or 
    • Meet any of the exceptions that may apply to these requirements. 

The law requires that a claimant complete and submit the Form SSA-4111, Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits to SSA.  SSA uses the information Form SSA-4111 provides to pay a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit provided they are age 62 and under their full retirement age (FRA).  The certificate of election permits as much as 12 months retroactivity and prevent loss of benefits for claimants who delay filing.   

When SSA receives a notification of the death of the NH directly from a funeral home, or an electronic death report, SSA automatically converts the beneficiary from spouse (or surviving divorced spouse) to widow(er), awards the Lump Sum Death payment (LSDP), and mails a notice inform him or her about the conversion.  The notice also includes a pre-addressed return envelope with the Form SSA-4111 and an explanation of the benefits due to the respondent on his or her own record and the suspension of the spouse benefit until the receipt of the SSA-4111.  

In situations where the claimant (surviving spouse) reports the death of the NH by contacting the field office (FO), the FO technician reviews the NH’s record and the survivor record to determine if SSA needs the certificate of election.  If SSA needs a certificate of election, the technician prints Form SSA-4111, and  hands or mails it to the beneficiary for completion and return to SSA.  Claimants who do not elect to complete and return the certificate will only continue to receive benefits under their own record and remain suspended on the deceased NH’s record until the claimant becomes eligible for resumption of benefits at full retirement age (FRA).  At FRA, SSA resumes any due payment.  

By completing the form, the claimant chooses when their benefits will start and agrees to receive reduced monthly payments, which will stay reduced even after they reach full retirement age.  SSA may also reducethe benefit amount based on the respondent’s date of birth or if other people become entitled to benefits on the deceased person's record.  In addition, the form explains how the survivor benefit may be limited or affected if the deceased worker received reduced retirement benefits, and that delaying receipt of a reduced survivor’s benefit will not necessarily increase the monthly benefit amount payable.  SSA will not pay reduced benefits to an already entitled spouse (or divorced spouse) who is:
    • At least age 62 and under full retirement age in the month of the NH’s death; and
    • Receiving both reduced spouse’s (or divorced spouse’s) benefits and either retirement or disability benefits in the month before the month of the NH’s death.

Form SSA-4111 is specific to a qualified dually entitled widow(er) (or surviving divorced spouse) who elects to receive a reduced widow(er) benefit provided he or she is age 62 and under their full retirement age (FRA).  Therefore, respondents are likely to learn about their options when they receive the notification and the form from SSA, or do research through the following methods:

    • Visiting the SSA public website page.  Our website informs the claimant about the benefits survivor may be eligible; 
    • Referral from other agencies (e.g., funeral homes, vital statistics, etc.); 
    • Talking to SSA employees when reporting the NH’s death; 
    • Receiving SSA notices, social-media postings on SSA’s website or blogs. 

When SSA receives the Form SSA-4111, a technician reviews the form to ensure there is no information missing and no further contact is needed.  In certain situations, technicians contact the claimant to inquire about the NH’s death (e.g., stop working or had a disability) as a claimant may file a disability application within 3 months after the NH’s death.  If SSA does not require any further clarification or action, the technician manually enters the information into the Certificate of Election (CELE) screen in the Post-entitlement Online System (POS) to document the election of reduced spouse’s benefits.  SSA only uses the CELE screen when the spouse files a Form SSA-4111 and he or she previously provided proof of his or her age which a technician recorded on the MBR.  If the claimant has not previously established proof of age in SSA records and is the respondent does not submit age information with the SSA-4111, SSA requires the technician to develop proof of age before entering the information into the CELE screen.  SSA maintains a copy of the SSA-4111 by scanning the form into the SSA electronic folder for the worker.

We identified the following psychological cost based on the requirements for this information collection:

Psychological Cost:
    • Requirement for the Program:  The SSA-4111 requires the applicant to make a decision regarding accepting a permanently reduced rate of payment.

    • Psychological Cost:  Respondents may find making the decision to accept permanently reduced benefits stressful, because of how it could affect their financial well-being in the future.
 
We understand psychological costs may cause respondents to delay their completion of the information collection or cause them to abandon the information collection entirely.  However, we require full completion of this collection, and we have taken this potential psychological cost into account when calculating our burden in #12 below.

The respondents are dually entitled widow(ers) (or surviving divorced spouse) who elect to receive a reduced widow(er) benefit provided they are age 62 and under their full retirement age (FRA).

    3. Use of Information Technology to Collect the Information
Form SSA-4111 is available on SSA’s website for respondents to download, print, complete and mail back to SSA.

This collection has a public-facing fillable and submittable version which the respondent can submit using SSA’s Upload Documents Portal (OMB No. 0960‑0830).  Upload Documents allows the respondent to complete the fillable PDF, electronically sign it, and submit the information through the Upload Documents Portal.  The submittable version mirrors the paper version and provides respondents with an online service option as an alternative to mailing, faxing, or bringing the form to an SSA field office.  Use of the Upload Documents Portal does not require respondents to download and install the application locally on their device or pay any subscription or licensing fees, and we account for the burden for using Upload Documents under OMB No. 0960-0830.  

    4. Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it preclude duplication.  SSA does not use another collection instrument to obtain similar data.  

    5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities. 

    6. Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-4111, dually entitled widow(er)s or surviving divorced spouses would not receive reduced widow(er) benefits, which would cause incorrect payments.  Because we only collect the information once, we cannot collect it less frequently.  There are no technical or legal obstacles to burden reduction.  

    7. Special Circumstances 
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

    8. Solicitation of Public Comment and Other Consultations with the Public 
The 60-day advance Federal Register Notice published on June 26, 2026, at 91 FR 38753, and we received no public comments.  The 30-day FRN published on August 27, 2026, at 91 FR 55418.  If we receive any comments in response to this Notice, we will forward them to OMB.  We did not consult with the public in the development revision of this form.

    9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents. 

    10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

    11. Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.

    12. Estimates of Public Reporting Burden
Please see the burden chart below:

Method of Completion
Number of Respondents
Frequency of Response
Average Burden Per Response (minutes)
Estimated Total Annual Burden (hours)
Average Theoretical Hourly Cost Amount (dollars)*
Average Wait Time in Field Office or Teleservice Centers 
(minutes) **
Total Annual Opportunity Cost
(dollars) **
SSA-4111 (paper)
6,266
1
13
1,358
$33.54*
21**
$119,101***
SSA-4111 (Upload Documents)
521
1
13
113
$33.54*
 
$3,790***
Totals
6,787


1,471


$122,891****
* We based this figure on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).

** We based this figure on the average FY 2026 wait times for field offices (average wait time of 21 minutes), based on SSA’s current management information data. This figure reflects data from our systems and the data posted on our public facing website (Social Security performance | SSA) on the date we drafted this document.  As the figures fluctuate, the wait times may be different on the website than they appear here.  We continue to monitor our website and management information data on call back times to ensure we report updated figures when possible.  While we have included wait time for all respondents using the paper form, we note that respondents are not required to complete the form in person and those who mail or drop off a completed form do not experience any wait time.

*** This figure does not represent actual costs that SSA is imposing on individuals; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the information collection.  There is no actual charge to respondents to complete the information collection.
 
In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection.  OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel.  We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office
Frequency of Response
Average One-Way Travel Time to a Field Office (minutes)
Estimated Total Travel Time to a Field Office (hours)
Total Annual Opportunity Cost for Travel Time (dollars)****
6,266
1
30
3,133
$105,081****
****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.”  SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport.  SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE:  We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument):

Total Number of Respondents 
Frequency of Response
Estimate Learning Cost (minutes)
Estimated Total Annual Burden (hours)
Total Annual Learning Cost (dollars)*****
6,787
1
	20
2,262
$75,867****
*****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

NOTE:  We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that 13 minutes accurately shows the average burden per response for learning about the program; receiving notices as needed; reading and understanding instructions; gathering the data and documents needed; answering the questions and completing the information collection instrument; scheduling any necessary appointment or required phone call; consulting with any third parties (as needed); and waiting to speak with SSA employees (as needed).  Based on our current management information data, the current burden information we provided is accurate.  The total burden for this ICR is 1,471 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $307,360.  SSA does not charge respondents to complete our applications.

13. 	Annual Cost to the Respondents (Other) 
This collection does not impose a known cost burden on the respondents.   

    14. Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $134,270.  This estimate accounts for costs from the following areas:

Description of Cost Factor
Methodology for Estimating Cost
Cost in Dollars*
Designing and Printing the Form
Design Cost + Printing Cost
$206
Distribution, Shipping, and Material Costs for the Form
Distribution + Shipping + Material Cost
	$4,887 
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time
GS-9 employee x # of responses x processing time
$127,307
Full-Time Equivalent Costs
Out of pocket costs + Other expenses for providing this service
$0*
Systems Development, Updating, and Maintenance
GS-9 employee x man hours for development, updating, maintenance
$1,870
Quantifiable IT Costs
Any additional IT costs
$0*
Total

$134,270
* We have inserted a $0 amount for cost factors that do not apply to this collection.
SSA is unable to break down the costs to the Federal government further than we already have.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.
15.	Program Changes or Adjustments to the Information Collection Request
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 8,328, 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.

16.  	Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.	Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms.  SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval.  Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste. 

    18. Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B.     	Collections of Information Employing Statistical Methods

	SSA does not use statistical methods for this information collection.