Information Collection

Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents)

IC 281854 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 (Upload D 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)	Form
Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
SSA-4111 (Upload D Certificate of Election for Reduced Widow(er)’s and Surv SSA-4111 (revised).pdf	Form
SSA-4111 (current).pdf SSA-4111 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.335

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4111 (Upload Documents)				Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement (revised)					Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 521

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	521	521
Annual IC Time Burden (Hours)	287	287
Annual IC Cost Burden (Dollars)	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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