Information Collection

Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)

IC 180150 under ICR 202608-0960-005 · OMB 0960-0759.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 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 (SSA-4111)	Form
Form 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 (SSA-4111)	Form
Privacy Act Statement (revised).docx	Other-Revised PA & PRA Statements
Privacy Act Statement (revised).docx	Other-Revised PA & PRA Statements
SSA-4111 CELE - Certificate of Election Screenshot.pdf	Other-CELE Screens
SSA-4111 CELE - Certificate of Election Screenshot.pdf	Other-CELE Screens
SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surv SSA-4111 (revised).pdf	Form
SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surv SSA-4111 (revised).pdf	Form
SSA-4111 (current).pdf SSA-4111 - Current	IC Document
SSA-4111 (current).pdf SSA-4111 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.335

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4111	Yes	No	Fillable Printable
Other-Revised PA & PRA Statements		No		Fillable Printable
Other-CELE Screens		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,266

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,266	-23,734	30,000
Annual IC Time Burden (Hours)	8,772	7,772	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4111 - Current		08/10/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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