Form SSA-10-INST (04-2017) UF
Destroy prior editions
Social Security Administration
REPORTING RESPONSIBILITIES FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS
Form Approved
OMB No. 0960 - 0004
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 $
a month.
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.
Custody Change or Disability Improves - Report if a
person for whom you are filing, or who is in your
care dies, leaves your care or custody, changes
address, or, if disabled, the condition improves.
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.
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).
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 required by law and adjust benefits under the
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
website 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 at the phone number and address
shown on your claim receipt.
For general information about Social Security, visit
our web site at www.socialsecurity.gov
NOTICE ABOUT DOCUMENTS
We recommend that you keep copies of all documents you submitted to us.
We are returning the documents you submitted with this claim.
(OVER)
