Fillable Printable Widow's or Widower's Insurance Benefits Application Form
Fillable Printable Widow's or Widower's Insurance Benefits Application Form
Widow's or Widower's Insurance Benefits Application Form
(Month, year)(Month, year)
Form SSA-10 (05-2014) EF (05-2014)
Destroy Prior Editions
APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
Form Approved
OMB No. 0960-0004
Page 1
TEL
TOE 120/145/155
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).
(Do not write in
this space)
1. (a) PRINT name of deceased wage earner or
self-employed person (herein referred to as
the "deceased")
(b) Check (X) one for the deceased
(a) PRINT your name
(c) Enter your name at birth if different from item 2(a)
PART I - INFORMATION ABOUT THE DECEASED
Enter date of birth of deceased MONTH, DAY, YEAR
(a) Enter date of death MONTH, DAY, YEAR
(b) Enter place of death
CITY AND STATE
Enter name of the State or foreign country where the deceased had a fixed,
permanent home at the time of death.
(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
(If "No," go
on to item 7.)
(b) Enter name(s) of person(s) on whose Social
Security record(s) other application was filed.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter Social Security Number(s) of person(s) named in (b).
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.
(a) Was the deceased unable to work because of illnesses, injuries or conditions
at the time of death?
(If "No," go on
to item 8.)
MONTH, DAY, YEAR
(If "No," go on
to item 9.)
(b) Enter dates of service.
FROM: TO:
(c) Has anyone (including the deceased) received, or does anyone expect to
receive, a benefit from any other Federal agency?
(Over)
SOCIAL SECURITY ADMINISTRATION
2.
3.
4.
(If "Yes," answer
(b) and (c).)
5.
7.
6.
(If "Yes,"
answer (b).)
(b) Enter the date the deceased became unable to work.
(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?
8.
(If "Yes," answer
(b) and (c).)
Male Female
FIRST NAME, MIDDLE INITIAL, LAST NAME
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter deceased's Social Security Number
(b) Enter your Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
Yes
No
Yes
No
Yes No
Yes No
If unknown, check this block
ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.
(a) About how much did the deceased earn from employment and
self-employment during the year of death?
Amount
(b) About how much did the deceased earn the year before death?
Amount
(a) Did the deceased have wages or self-employment income covered under
Social Security in all years from 1978 through last year?
(If "Yes," skip
to item 11.)
(If "No,"
answer (b).)
CHECK IF APPLICABLE:
INFORMATION ABOUT THE DECEASED'S MARRIAGE(S)
(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)
When (Month, Day, and Year)
Where (Name of City and State)
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)
How Marriage Ended
When (Month, Day, and Year) Where (Name of City and State)
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
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.")
PART II - INFORMATION ABOUT YOURSELF
(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?
(c) Was a religious record of your birth made before age 5?
Form SSA-10 (05-2014) EF (05-2014)
9.
10.
11.
Answer this item ONLY if the deceased had other marriages.
12.
How Marriage Ended
Marriage performed by
Marriage performed by:
13.
14.
Page 2
(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.
$
$
Yes No
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 any increase in my benefits will be paid
with full retroactivity.
Clergyman or public official
Other (Explain in Remarks)
Other (Explain in Remarks)
Clergyman or public official
NoYes
Yes
Yes
No
No
Unknown
Unknown
Form SSA-10 (05-2014) EF (05-2014)
Marriage performed by:
Other (Explain in Remarks)
Clergyman or public official
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)
How Marriage Ended
When (Month, Day, and Year) Where (Name of City and State)
Spouse's date of birth (or age)
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)
How Marriage Ended
When (Month, Day, and Year) Where (Name of City and State)
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)
How Marriage Ended
When (Month, Day, and Year) Where (Name of City and State)
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.
(a) Were you and the deceased living together at the same address when
the deceased died?
(If "Yes," skip to
item 17.)
(If "No," answer
(b).)
(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?
Reason you were apart at time of death:
If separated because of illness, enter nature of illness or disabling condition.
(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," go on
to item 18.)
(b) Enter name of person on whose Social Security record
you filed other application.
(c) Enter Social Security Number of person named in (b).
(if unknown, so indicate)
(Over)
15.
Marriage performed by:
Marriage performed by:
16.
17.
(If "Yes," answer
(b) and (c).)
Page 3
Other (Explain in Remarks)
Clergyman or public official
Other (Explain in Remarks)
Clergyman or public official
NoYes
Deceased Surviving spouse
Date last at home:
Reason absence began:
NoYes
Form SSA-10 (05-2014) EF (05-2014)
I have not applied for but I expect to begin
receiving my pension or annuity:
I applied for and am awaiting a decision on my
pension or lump sum.
NoYes
Yes No
Yes
Page 4
DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19.
(a) Are you, or during the past 14 months have you been, unable to work
because of illnesses, injuries or conditions?
(If "Yes," answer
(b) .)
(If "No," go on to
item 19.)
(Month, day, year)
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?
Did you or the deceased work in the railroad industry for 5 years
or more?
(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 "Yes," answer
(b).)
(If "No," go on to
item 22.)
(b) If "Yes," list the country(ies).
(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 "Yes," check
which of the items
in item (b) applies
to you.)
(If "No," go
on to item 23.)
(b)
(Month, year)
(If the date is not known, enter "Unknown".)
MEDICARE INFORMATION
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.
Do you want to enroll in the Medicare Part B (Medical Insurance)?
18.
(b) Enter the date you became unable to work.
19.
20.
21.
22.
23.
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.
NoYes
NoYes
No
I receive a government pension or annuity.
I received a lump sum in place of a government
pension or annuity.
NoYes
Form SSA-10 (05-2014) EF (05-2014)
Dec.Nov.Oct.Sept.
May Jun. Jul. Aug.
Apr.Mar.Feb.Jan.
Dec.Nov.Oct.Sept.
May Jun. Jul. Aug.
Apr.Mar.Feb.Jan.
May
Jan. Feb. Mar. Apr.
Jun. Jul. Aug.
Sept. Oct. Nov. Dec.
Page 5
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."
25.
(a) How much do you expect your total earnings to be this year?
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?
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.
Month
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?
(Over)
(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."
(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."
IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. OTHERWISE, PLEASE READ CAREFULLY
THE INFORMAITON 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.
(c) I want benefits beginning with . I understand that either a higher initial payment or a higher
continuing monthly benefit amount may be possible, but I choose not to take it.
NONE ALL
NONE ALL
NONE ALL
NoYes
Form SSA-10 (05-2014) EF (05-2014)
Enroll in Direct Express
Savings
Checking
Page 6
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)
Telephone number(s) at which you
may be contacted during the day
City and State
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)
2. Signature of Witness
Address (Number and street, City, State and zip Code)
AREA CODE
Direct Deposit Payment Address (Financial Institution)
Account Number
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
Direct Deposit Refused
Routing Transit Number
Applicant's Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
(Enter Residence Address in "Remarks," if different.)
ZIP Code
Form SSA-10 (05-2014) EF (05-2014)
SSA OFFICE
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR
SOMETHING TO REPORT
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.
DECEASED'S SURNAME IF
DIFFERENT FROM CLAIMANT'S
SOCIAL SECURITY CLAIM
NUMBER
PRIVACY ACT NOTICE
Collection and Use of Personal Information
- 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 control number. We estimate that it will take about 15 minutes to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED REPORT TO YOUR
LOCAL SOCIAL SECURITY OFFICE, THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. You can find your
local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U.S.
Government agencies in your telephone directory or you may call 1-800-772-1213 (TTY 1-800-325-0778) for the
address. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed report.
(Over)
Page 7
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 make a decision on this claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent an
accurate and timely decision on any claim filed, or could result in loss of benefits.
We rarely use the information you supply us for any purpose other than to determine entitlement to Social Security benefits.
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,
Claim Folders System, 60-0089. 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
BEFORE YOU RECEIVE A
NOTICE OF AWARD
AFTER YOU RECEIVE A
NOTICE OF AWARD
DATE CLAIM RECEIVED
CLAIMANT
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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) self-employed rendering
substantial services in your trade or business.
You (are) (are not) earning wages of more than
$ a month.
(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 government pension or annuity (from
the federal government or any State or any political
subdivision thereof) or your pension or annuity amount
changes.
You have an unsatisfied arrest warrant for more than 30
continuous days for flight to avoid prosecution or confinement,
escape from custody, or flight-escape.
You are violating a condition of probation or parole
imposed under Federal or State law.
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;
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 earnings both before and after retirement, 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.
FIGURING YOUR ANNUAL EARNINGS
Form SSA-10 (05-2014) EF (05-2014)
Page 8
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
