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Ssa-10 APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS

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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
(c) Enter deceased's Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
2. (a) PRINT your name
(b) Enter your Social Security Number
FIRST NAME, MIDDLE INITIAL, LAST NAME
(c) Enter your name at birth if different
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.
(c) Enter Social Security Number(s) of person(s) named in (b).
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.)
No
(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.)
No
(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:
(c) Has anyone (including the deceased) received, or does anyone
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
Amount
$
$
(If "No,"
answer (b).)
No
(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?
(c) Was a religious record of your birth made before age 5?
Yes No Unknown
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).)
No
(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).)
No
(If "Yes," skip to
item 17.)
Yes
(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)
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
No
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).)
No
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.)
No
(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.
(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.
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.
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