Fillable Printable Application For Widow'S Or Widower'S Insurance Benefits

Application For Widow'S Or Widower'S Insurance Benefits

SOCIAL SECURITY ADMINISTRATION

TEL TOE 120/145/155

Form Approved

OMB No. 0960-0004

Form SSA-10 (06-2017) UF

Destroy Prior Editions

Page 1 of 8

APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS* (Do not write in this space)

With this application, you are applying for all insurance benefits for which you are eligible under

Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health

Insurance for the Aged and Disabled) of the Social Security Act as presently amended. The

information you furnish on this application will ordinarily be sufficient for a determination on the

lump-sum death payment.?If you were receiving spouse's benefits at the time of your spouse's

death, you only need to complete the circled items. All other claimants must complete the entire

form.?*This may also be considered an application for survivors benefits under the Railroad

Retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits,

Chapter 13 (which is, as such, an application for other types of death benefits under title 38).

1. (a) PRINT name of deceased wage earner or

self-employed person (herein referred to as

the "deceased")

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Check (X) one for the deceased

Male Female

FIRST NAME, MIDDLE INITIAL, LAST NAME

2. (a) PRINT your name

(b) Enter your Social Security Number

FIRST NAME, MIDDLE INITIAL, LAST NAME

from item 2(a)

PART I - INFORMATION ABOUT THE DECEASED

3. Enter date of birth of deceased MONTH, DAY, YEAR

MONTH, DAY, YEAR4. (a) Enter date of death

CITY AND STATE(b) Enter place of death

5. Enter name of the State or foreign country where the deceased had

a fixed, permanent home at the time of death.

6. (a) Did the deceased ever file an application for Social Security

benefits, a period of disability under Social Security, supplemental

security income, or hospital or medical insurance under Medicare?

If unknown, check this box

NoYes

(If "Yes," answer

(b) and (c).)

(If "No," go

on to item 7.)

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter name(s) of person(s) on whose

Social Security record(s) other application

was filed.

If unknown, check this box

Answer Item 7 Only if the Deceased Died Prior to Full Retirement Age or Prior to 1 Year Past Full Retirement Age, and

Within the Past 4 Months.

(If "No," go on

to item 8.)

(If "Yes," answer (b).)

Yes

7. (a) Was the deceased unable to work because of illnesses, injuries

or conditions at the time of death?

MONTH,DAY,YEAR(b) Enter the date the deceased became unable to work.

(If "No," go on

to item 9.)

(If "Yes," answer

(b) and (c).)

Yes

8. (a) Was the deceased in the active military or naval service

(including Reserve or National Guard active duty or active duty

for training) after September 7, 1939 and before 1968?

(b) Enter dates of service.

(Month, year) (Month, year)

FROM: TO:

expect to receive, a benefit from any other Federal agency?

NoYes

Form SSA-10 (06-2017) UF Page 2 of 8

ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.

9. (a) About how much did the deceased earn from employment and

self-employment during the year of death?

(b) About how much did the deceased earn the year before death?

10. (a) Did the deceased have wages or self-employment income

covered under Social Security in all years from 1978 through

last year?

(b) List the years from 1978 through last year in which the

deceased did not have wages or self-employment income

covered under Social Security.

Amount

(If "No,"

answer (b).)

(If "Yes," skip to

item 11.)

Yes

11. CHECK IF APPLICABLE

I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these

earnings will be included automatically within 24 months, and retroactivity.

INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)

12. Answer this item ONLY if the deceased had other marriages.

(a) If the deceased married after his or her marriage to you, enter the information on the last marriage.

(If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

Where (Name of City and State)When (Month, Day, and Year)

How Marriage Ended

Clergyman or public official

Other (Explain in Remarks)

Marriage performed by

Spouse's date of birth (or age)

If spouse deceased, give date

of death

Spouse's Social Security Number (If none or unknown, so indicate)

(b) If the deceased had any other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse

(whether before or after you married the deceased), enter the information below. If the deceased divorced then remarried

the same individual within the year immediately following the year of the divorce, and the combined period of marriage

totaled 10 years or more, include the marriage. (If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

Where (Name of City and State)

When (Month, Day, and Year)

How Marriage Ended

Clergyman or public official

Other (Explain in Remarks)

Marriage performed by

Spouse's date of birth (or age)

If spouse deceased, give date

of death

Spouse's Social Security Number (If none or unknown, so indicate)

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER PREVIOUS MARRIAGE AS

DESCRIBED IN 12b.

13. Is there a surviving parent (or parents) who was receiving support from the deceased

at the time of death or at the time the deceased became disabled under

Social Security Law?

(If "Yes," enter the name

and address in"Remarks.")

Yes

PART II - INFORMATION ABOUT YOURSELF

14. (a) Enter name of State or foreign country where you were born.

If you have already presented, or if you are now presenting, a public or religious record of your birth established before you

were age 5, go on to item 15.

(b) Was a public record of your birth made before age 5?

Yes No Unknown

Form SSA-10 (06-2017) UF Page 3 of 8

15. INFORMATION ABOUT YOUR MARRIAGE(S)

(a) Enter information about your marriage to the deceased.

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

Where (Name of City and State)When (Month, Day, and Year)

How Marriage Ended

Clergyman or public official

Other (Explain in Remarks)

Marriage performed by

Spouse's date of birth (or age)

If spouse deceased, give date

of death

Spouse's Social Security Number (If none or unknown, so indicate)

(b) If you remarried after the marriage shown in 15.(a). enter information about the last marriage. (If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

Where (Name of City and State)

When (Month, Day, and Year)

How Marriage Ended

Clergyman or public official

Other (Explain in Remarks)

Marriage performed by

Spouse's date of birth (or age)

If spouse deceased, give date

of death

Spouse's Social Security Number (If none or unknown, so indicate)

(c) Enter information about any other marriage you may have had that lasted at least 10 years (see item 12(b) for counting

consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or after you married

the deceased). (If none, write "NONE".)

Spouse's Name (including maiden name) When (Month, Day, and Year) Where (Name of City and State)

Where (Name of City and State)

When (Month, Day, and Year)

How Marriage Ended

Clergyman or public official

Other (Explain in Remarks)

Marriage performed by

Spouse's date of birth (or age)

If spouse deceased, give date

of death

Spouse's Social Security Number (If none or unknown, so indicate)

USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER MARRIAGE AS DESCRIBED IN 15c.

IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17.

16. (a) Were you and the deceased living together at the

same address when the deceased died?

No(If "No,"

answer (b).)

(If "Yes," skip to

item 17.)

Yes

(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died, give the

following: Who was away?

Surviving SpouseDeceased

Date last at home: Reason absence began: Reason you were apart at time of death:

If separated because of illness, enter nature of illness or disabling condition.

17. (a) Have you (or has someone on your behalf) ever filed

an application for Social Security benefits, a period of

disability under Social Security, Supplemental Security

Income, or hospital or medical insurance under Medicare?

(If "No,"

answer (b).)

(If "Yes," skip to

item 17.)

Yes

(b) Enter name of person on whose Social Security record you

filed other application.

unknown, so indicate)

Form SSA-10 (06-2017) UF Page 4 of 8

DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19.

18. (a) Are you, or during the past 14 months have you been,

unable to work because of illnesses, injuries or conditions?

(If "No," go on

to item 19.)

(If "Yes," answer

(b) .)

(b) Enter the date you became unable to work.

(Month, day, year)

19. Were you in the active military or naval service (including

Reserve or National Guard active duty or active duty for

training) after September 7, 1939 and before 1968?

NoYes

Yes

20. Did you or the deceased work in the railroad industry for 5

years or more?

NoYes

21. (a) Did you or the deceased have Social Security credits

(for example, based on work or residence) under another

country's Social Security System?

(If "No," go on

to item 22.)

(If "Yes," answer

(b).)

Yes

(b) If "Yes," list the country(ies)

22. (a) Have you qualified for, or do you expect to qualify

for, a pension or annuity (or a lump sum in place of a pension

or annuity) based on your own employment and earnings for the

Federal Government of the United States, or one of its States

or local subdivisions that was not covered under Social

Security? (Social Security benefits are not

government pensions.)

(If "No," go on

to item 23.)

(If "Yes," check

which of the items

in item (b) applies

to you.)

Yes

(b)

I receive a government pension or annuity.

I received a lump sum in place of a

government pension or annuity.

I applied for and am awaiting a decision on my

pension or lump sum.

I have not applied for but I expect to begin

receiving my pension or annuity:

(Month, day, year)

(If the date is not known, enter "Unknown".)

MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of Age 65 or older you could

automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you

live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to

contact Social Security to request enrollment.

COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER

Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that

Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care.

If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when

your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the

Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of

Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to

pay your premiums. You will also get a letter if there is any change in the amount of your premium.

You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and

when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also

can tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium

varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan

premium, based on information about your income we receive from the Internal Revenue Service.

If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with

Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles and prescription co-

payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the

nearest Social Security office.

NoYes

23.Do you want to enroll in the Medicare Part B (Medical Insurance)?

Page 5 of 8Form SSA-10 (06-2017) UF

ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR.

24.(a) How much were your total earnings last year?

(b) Place an "X" in each block for each month of last year in which you did

not earn more than *$ in wages, and did not perform

substantial services in self-employment. These months are exempt

months. If no months were exempt months, place an "X" in "NONE."

If all months were exempt months, place an "X" in "ALL."

*Enter the appropriate monthly limit after reading the information,

"How Work Affects Your Benefits."

Jan.

Feb.

Apr. Mar.

NONE ALL

May

Jun.

Aug. Jul.

Sept.

Oct.

Dec.Nov.

25. (a) How much do you expect your total earnings to be this year?

(b) Place an "X" in each block for each month of this year in which you did

not or will not earn more than *$ in wages, and did not or will

not perform substantial services in self-employment. These months are

exempt months. If no months are or will be exempt months, place an "X"

in "NONE." If all months are or will be exempt months, place an

"X" in "ALL."

*Enter the appropriate monthly limit after reading the information, "How Work

Affects Your Benefits."

Jan.

Feb.

Apr. Mar.

NONE ALL

May

Jun.

Aug. Jul.

Sept.

Oct.

Dec.Nov.

ANSWER ITEM 26 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT.,

OCT., NOV., AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR).

26. (a) How much do you expect to earn next year?

(b) Place an "X" in each block for each month of next year in which you do

not expect to earn more than *$ in wages, and do not expect

to perform substantial services in self-employment. These months will be

exempt months. If no months are expected to be exempt months, place

an "X" in "NONE." If all months are expected to be exempt months, place

an "X" in "ALL."

*Enter the appropriate monthly limit after reading the

information, "How Work Affects Your Benefits."

Jan.

Feb.

Apr. Mar.

NONE ALL

May

Jun.

Aug. Jul.

Sept.

Oct.

Dec.Nov.

Month

27. If you use a fiscal year, that is, a taxable year that does not end

December 31 (with income tax return due April 15), enter here the

month your fiscal year ends.

IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO ITEM 29. OTHERWISE, PLEASE READ CAREFULLY THE

INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS.

28.

(a) I want benefits beginning with the earliest possible month.

(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible month,

providing that there is no permanent reduction in my ongoing monthly benefits.

monthly benefit amount may be possible, but I choose not to take it.

ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS.

29. Do you wish this application to be considered an application for

retirement benefits on your own earnings record?

NoYes

Page 6 of 8Form SSA-10 (06-2017) UF

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)

_______________________________________________________________________________________________________

Direct Deposit Payment Address (Financial Institution)

Routing Transit Number

Account Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying

statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly

gives a false or misleading statement about a material fact in this information, or causes someone else to do so,

commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

AREA CODE

Telephone number(s) at which you may

be contacted during the day

Applicant's Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

(Enter Residence Address in "Remarks," if different.)

City and State ZIP Code Country (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the

signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the

Signature block.

1. Signature of Witness

Address (Number and street, City, State and zip Code) Address (Number and street, City, State and zip Code)

2. Signature of Witness

Page 7 of 8Form SSA-10 (06-2017) UF

TELEPHONE NUMBER(S)

TO CALL IF YOU HAVE A

QUESTION OR

SOMETHING TO REPORT

BEFORE YOU RECEIVE A

NOTICE OF AWARD

SSA OFFICE

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS

AFTER YOU RECEIVE A

NOTICE OF AWARD

DATE CLAIM RECEIVED

Your application for Social Security benefits has been received

and will be processed as quickly as possible.

You should hear from us within days after you have given

us all the information we requested. Some claims may take

longer if additional information is needed.

In the meantime, if you change your address, or if there is some

other change that may affect your claim, you - or someone for

you - should report the change. The changes to be reported are

listed on page 8. Always give us your claim number when

writing or telephoning about your claim.

If you have any questions about your claim, we will be glad to

help you.

CLAIMANT

DECEASED'S SURNAME IF

DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY CLAIM

NUMBER

PRIVACY ACT NOTICE

Collection and Use of Personal Information

Sections 202, 205, and 233 of the Social Security Act, as amended, authorize us to collect this information. We will use the

information you provide to determine eligibility of you or a dependent for Social Security benefits.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent us from

making an accurate and timely decision on your entitlement or a dependent's entitlement to Social Security benefit payments.

We rarely use the information you supply us for any purpose other than for making a determination relating to your entitlement or

a dependent's entitlement to Social Security benefit payments. However, we may use it for the administration and integrity of

Social Security programs. We may also disclose information to another person or to another agency in accordance with approved

routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government

Accountability Office and Department of Veterans' Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;

and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social

Security programs (e.g., to the Bureau of the Census).

We may also use the information you give us in computer matching programs. Matching programs compare our records with

records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to

establish or verify a person's eligibility for federally-funded or administered benefit programs and for repayment of payments or

delinquent debts under these programs.

A complete list of routine uses of the information you provided us is available in our System of Records Notice entitled, Master

Beneficiary Record, 60-0090. This notice, additional information regarding this form, and information regarding our programs and

systems, are available on-line at www.socialsecurity.gov

or at your local Social Security office.

Paperwork Reduction Act Statement

- This information collection meets the requirements of 44 U.S.C.§ 3507, as amended by

section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of

Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0004. We estimate that it

will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to

our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Page 8 of 8Form SSA-10 (06-2017) UF

CHANGES TO BE REPORTED AND HOW TO REPORT

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE

MONETARY PENALTIES.

• You change your mailing address for checks or residence.

(To avoid delay in receipt of checks you should ALSO file a

regular change of address notice with your post office.)

• Your citizenship or immigration status changes.

• You go outside the U.S.A. for 30 consecutive days or longer.

• Any beneficiary dies or becomes unable to handle benefits.

• Work Changes - On your application you told us you expect

total earnings for to be $ .

You (are) (are not) earning wages of more than

$ a month

You (are) (are not) self-employed rendering substantial

services in your trade or business.

(Report AT ONCE if this work pattern changes.)

• Change of Marital Status - Marriage, divorce, annulment of

marriage. You must report a change in marital status even if

you believe that an exception applies.

• You are confined for more than 30 continuous days to jail,

prison, penal institution, or correctional facility for conviction

of a crime or you are confined to a public institution by court

order in connection with a crime.

• Custody Change - Report if a person for whom you are filing,

or who is in your care dies, leaves your care or custody, or

changes address.

• You begin to receive a pension, annuity, or a lump sum

payment based on your government employment not covered

by Social Security or your pension or annuity amount

changes or stops.

• You have an unsatisfied warrant for more than 30 continuous

days for your arrest for a crime or attempted crime that is a

felony or flight to avoid prosecution or confinement, escape

from custody, and flight-escape. In most jurisdictions that do

not classify crimes as felonies, this applies to a crime that is

punishable by death or imprisonment for a term exceeding 1

year (regardless of the actual sentence imposed).

Disability Applicants

1. You return to work (as an employee or self-employed)

regardless of amount of earnings.

2. Your condition improves.

WORK AND EARNINGS

For those under full retirement age, the law requires that a

report of earnings be filed with SSA within 3 months and 15

days after the end of any taxable year in which you earn more

than the annual exempt amount. You may contact SSA to file a

report. Otherwise, SSA will use the earnings reported by your

employer(s) and your self-employment tax return (if applicable)

as the report of earnings test. It is your responsibility to ensure

that the information you give concerning your earnings is

correct. You must furnish additional information as needed

when your benefit adjustment is not correct based on the

earnings on your record.

HOW TO REPORT

You can make your reports by telephone, mail, in person, or

online, whichever you prefer. If you are awarded benefits, and

one or more of the above change(s) occur, you should report

by:

• Visiting the section "What You Can Do Online" at our web

site at www.socialsecurity.gov

;

• Calling us TOLL FREE at 1-800-772-1213;

• If you are deaf or hearing impaired, calling us TOLL FREE

at TTY 1-800-325-0778; or

• Calling, visiting or writing your local Social Security office

shown at the phone number and address on your

claim receipt.

For general information about Social Security, visit our web

site at www.socialsecurity.gov.

FIGURING YOUR ANNUAL EARNINGS

To figure your total yearly earnings, count all gross wages (before deductions) and net earnings from self-employment which you

earn during the entire year. This includes earning both before and after your retirement date, and applies to all earned income

whether or not covered by Social Security.

In figuring your total yearly earnings, however, DO NOT COUNT ANY AMOUNTS EARNED BEGINNING WITH THE MONTH

YOU ATTAIN FULL RETIREMENT AGE. Count only amounts earned before the you attain full retirement age.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE ANSWERING QUESTION 28.

Benefits may be payable for some months prior to the month in which you file this claim (but not for any month before you reach

age 60 (unless you are disabled)) if:

• YOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR.

(For the appropriate exempt amount, see "How Work Affects Your Benefits.")

If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually

receive your full benefit amount for one or more months before full retirement age because benefits are withheld due to your

earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at full

retirement age will be reduced only you receive one or more full benefit payments prior to the month you attain full retirement age.