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Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0960-0759 · SSA.

OMB 0960-0759

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.

The latest form for Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits expires 2026-09-30 and is listed under ICR 202204-0960-006.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-4111 (Upload D Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s BenefitsForm
Form SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s BenefitsForm
Supporting Statement - 0759 (final).docxSupporting Statement A
Addendum 0759.docxSupplementary Document
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents) Form
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (Upload Documents) Other-Privacy Act Statement (revised)
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111) Form
Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111) Other-Revised PA & PRA Statements

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202608-0960-005 Revision of a currently approved collection 2026-08-27
202204-0960-006 Revision of a currently approved collection 2022-09-02 Approved without change
201901-0960-007 Revision of a currently approved collection 2019-05-24 Approved with change
201601-0960-007 Revision of a currently approved collection 2016-04-28 Approved without change
201302-0960-006 Revision of a currently approved collection 2013-05-29 Approved without change
201006-0960-012 Revision of a currently approved collection 2010-08-12 Approved without change
200903-0960-001 No material or nonsubstantive change to a currently approved collection 2009-06-02 Approved without change
200705-0960-007 Existing collection in use without an OMB Control Number 2007-09-07 Approved with change