Fillable Ssa-2-bk APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS

Fill Online, Printable, Fillable, Blank Ssa-2-bk APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS Form

Use Fill to complete blank online U.S. SOCIAL SECURITY ADMINISTRATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ssa-2-bk APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS

On average this form takes 38 minutes to complete

The Ssa-2-bk APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS form is 8 pages long and contains:

  • 1 signature
  • 100 check-boxes
  • 101 other fields

Country of origin: US
File type: PDF

BROWSE U.S. SOCIAL SECURITY ADMINISTRATION FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
(a) PRINT Name of Wage Earner or Self-
Employed Person
(Herein referred to as the "Worker")
OMB No 0960-0618
(a) Are you a U.S. citizen?
(b) Have you used any other name(s)?
MONTH, DAY, YEAR
(b) Enter name of city and state, or foreign country where you were born
(b) Are you an alien lawfully present in U.S.?
(c) Other name(s) used.
(a) Enter your full name at birth if different from
item 3(a)
FIRST NAME, MIDDLE INITIAL, LAST NAME
FIRST NAME, MIDDLE INITIAL, LAST NAME
Answer question 4 if English is not your preferred language. Otherwise go to item 5.
Enter the language you prefer to:
(a) Enter your date of birth
Check (X) whether you are
(d) Was a religious record of your birth made before you were age 5?
(c) Was a public record of your birth made before you were age 5?
(b) Enter Worker's Social Security Number
3.
(a) PRINT your name
(b) Enter your Social Security Number
5.
Yes UnknownNo
Yes No Unknown
1.
2.
Write
4.
6.
Speak
Female
Male
No
Yes
No (Go to item 7)Yes (Go to item (c))
NoYes
FIRST NAME, MIDDLE INITIAL, LAST NAME
8.
(a) Have you used any other Social Security number(s)?
NoYes
Supplement. If you have already completed an application entitled "APPLICATION
FOR RETIREMENT INSURANCE BENEFITS", you need complete only the circled
items. All other claimants must complete the entire form.
SOCIAL SECURITY ADMINISTRATION
APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS
I apply for all insurance benefits for which I am 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.
(Do not write in this space)
(If "Yes," go to item 7.)
(If "Yes," answer (c).)
(If "No," answer (b).)
(If "No," go to Item 8.)
7.
(c) When were you lawfully admitted to the U.S.?
(b) Enter Social Security number(s) used.
Form SSA-2-BK (07-2018) UF
Discontinue Prior Editions
Page 1 of 8
Form SSA-2-BK (07-2018) UF
(b) Check one box and provide the date in (c)
(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?
(b) Enter name of person(s) on whose Social Security
record you filed other application.
(c) Enter Social Security Number(s) of person named in
(b). (If unknown, so indicate)
(MONTH, YEAR)
(b) List the other country (ies).
From: To:
(a) 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 your spouse, (or prior spouse) work in the railroad
industry for 5 years or more?
(a) Do you have Social Security credits (for example, based on
work or residence) under another country's Social Security
system?
(b) If “Yes” when do you believe your condition(s) became
severe enough to keep you from working (even if you have
never worked)?
(b) Enter date(s) of service
(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 15.)
DO NOT ANSWER QUESTION 9 IF YOU ARE ONE YEAR PAST FULL RETIREMENT AGE OR OLDER.
GO ON TO QUESTION 10.
MONTH, DAY, YEAR
9.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(If "No," go to item 11.)
(If "No," go to item 12.)
10.
11.
12.
13.
(If "No," go to item 14.)
No
Yes
Yes No
Yes No
NoYes
NoYes
Yes No
14.
(If "Yes," check which
of the items in item (b)
applies to you.)
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.
(a) Are you entitled to, or do you expect to be entitled to a
pension or annuity (or a lump sum in place of a pension or
annuity) based on your own employment and earnings from
the Federal government of the United States, or one of its
States or local subdivisions? (Social Security benefits are not
government pensions.)
Yes No
I have not applied for but I expect to begin receiving my pension
or annuity.
(c) MONTH YEAR
(If "Yes," answer(b).)
(If "Yes," answer (b)
and (c).)
(If "Yes," answer (b)
and (c).)
(If "Yes," answer (b).)
(If the date is not known,
enter "Unknown".)
(If "No," go to item 10.)
I agree to promptly notify the Social Security Administration if I become
entitled to a pension, an annuity, or a lump sum payment based on my
employment not covered by Social Security, or if my pension or annuity
amount changes or stops.
(MONTH, YEAR)
(c) Have you ever been (or will you be) eligible for monthly
benefits from a military or civilian Federal agency (Include
Veterans Administration benefits only if you waived Military
retirement pay)?
Page 2 of 8
Form SSA-2-BK (07-2018) UF
Marriage performed by:
(a) Enter information about your marriage to the worker. If you married the worker more than once, use the
'Remarks' space to enter the additional marriage information. Go to item 15(b) if you are filing as a divorced
spouse; otherwise, go to item 15(c)
Spouse's Social Security Number (If none or unknown, so indicate)
Marriage performed by:
Spouse's name (including maiden name) When (Month, day, year)
When (Month, day, year) Where (Name of City and State)
Spouse's date of birth (or age) If spouse deceased, give date of death
Page 3 of 8
Other (Explain in "Remarks")
Clergyman or public official
Where (Name of City and State)
(b) If you remarried after the divorce from the worker, enter the marriage information. If you did not remarry, write
"None" Go on to item 15(c) if you had other marriages.
How marriage ended (If still in effect,
write "Not Ended.")
Marriage performed by:
Spouse's Social Security Number (If none or unknown, so indicate)
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)
How marriage ended When (Month, day, year) Where (Name of City and State)
Clergyman or public official
Other (Explain in "Remarks")
Spouse's date of birth (or age) If spouse deceased, give date of death
If you are now under full retirement age or less than one year past full retirement age, answer question 16.
If you are more than one year past full retirement age, go to question 17.
(Use "Remarks" space on page 5 for information about any other marriages.)
Spouse's Social Security number (If none or unknown, so indicate)
To whom married When (Month, day, year) Where (Name of City and State)
How marriage ended When (Month, day, year) Where (Name of City and State)
Clergyman or public official
Spouse's date of birth (or age) If spouse deceased, give date of death
(c) Enter information about any marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
• Were divorced, 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. Use the "Remarks" space to enter the additional
marriage information. Do not repeat any marriages listed in item 16(a) or 16(b). If none, write "None". _________
15.
Other (Explain in "Remarks")
Answer this item 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).
19.
(a) How much were your total earnings last year?
$
18.
NONE
(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 inself-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 instructions,
"How Work Affects Your Benefits".
(a) How much do you expect your total earnings to be this year?
$
*Enter the appropriate monthly limit after reading the instructions,
"How Work Affects Your Benefits".
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
(a) How much do you expect to earn next year?
$
20.
Dec.
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 need more space, use "Remarks")
Enter below the names and addresses of all the persons, companies, or government agencies for whom you have
worked this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO THE
INSTRUCTIONS FOR ITEM 21.
17.
Month Year
Month Year
NAME AND ADDRESS OF EMPLOYER
(If you had more than one employer, please list them
in order beginning with your last (most recent) employer).
Work Began
Work Ended
(If still working,
Show "Not
Ended")
Month
16.
Has an unmarried child of the worker (including adopted child, or stepchild) or a
dependent grandchild of the worker (including stepgrandchild) who is under 16 or
disabled lived with you during any of the last 13 months (counting the present month)?
(If "Yes, "enter the information requested below)
Name of child Months child lived with you (if all, write "All")
Yes No
(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".
NONE
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
Dec.
NONE
Mar. Apr.
May Jun. Jul. Aug.
Sept. Oct. Nov.
Feb.Jan.
ALL
Dec.
*Enter the appropriate monthly limit after reading the instructions,
"How Work Affects Your Benefits".
(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".
Form SSA-2-BK (07-2018) UF
Page 4 of 8
Do you want to enroll in Medicare Part B (Medical Insurance)?
NoYes
No
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
If you are within 2 months of age 65 or older, blind or disabled,
do you want to file for Supplemental Security Income?
COMPLETE ITEM 22 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 does not 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.
Late Enrollment Penalty
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as
you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have
had Part B, but did not sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to
March 31) to enroll in Part B, and coverage will start July 1 of that year.
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 can also 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.
(c) I want benefits beginning with .
21.
(a) I want benefits beginning with the earliest possible month and will accept an age related reduction.
(b) I am full retirement age (or will be within 12 months) and want benefits beginning with the earliest
possible month providing there is no permanent reduction in my ongoing monthly benefits.
If you are now under full retirement age and do not have an entitled child in your care, answer item 21. If you
are full retirement age or older or you have an entitled child in your care, go to item 22.
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.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF
THE FOLLOWING ITEMS.
22.
Yes
23.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Page 5 of 8
Form SSA-2-BK (07-2018) UF
Telephone number(s) at which
you may be contacted during
the day
Address (Number and Street, City, State and ZIP Code)
City and State
Direct Deposit Payment Information (Financial Institution)
SIGNATURE OF APPLICANT
Date (Month, day, year)
Routing Transit Number Account 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 County (if any) in which you now live
1. Signature of Witness 2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
SIGNATURE (First Name, Middle Initial , Last Name) (Write in ink)
Direct Deposit Refused
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the
Signature block.
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 face other penalties, or both.
REMARKS (con't.)
Enroll in Direct Express
Checking
Savings
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Page 6 of 8
Form SSA-2-BK (07-2018) UF
click to sign
signature
click to edit
CLAIMANT
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIFE'S OR HUSBAND'S INSURANCE BENEFITS
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 have a change of address,
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOME-
THING TO REPORT
DATE CLAIM RECEIVED
or if there is some other change that may affect your
claim, you - or someone for you - should report the
change to the telephone number shown above. 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.
SOCIAL SECURITY NUMBERWORKER'S SURNAME IF
DIFFERENT FROM CLAIMANT'S
BEFORE YOU RECEIVE
A NOTICE OF AWARD
AFTER YOU RECEIVE A
NOTICE OF AWARD
SSA OFFICE
- 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 11 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY 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 Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Sections 202, 205, 223 and 1872 of the Social Security Act, as amended, allow us to collect this information. Furnishing
us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and
timely decision on any claim filed.
We will use the information to make a determination of eligibility for benefits for you and your dependents. We may also
share your information for the following purposes, called routine uses:
1. To any source that has, or is expected to have, information that the Social Security Administration (SSA) needs
in order to establish or verify a person's eligibility for a certificate of coverage under a Social Security agreement
authorized by section 233 of the Social Security Act (Act); and
2. To private medical and vocational consultants for use in making preparation for, or evaluation the results of,
consultative medical examinations or vocational assessments which they were engaged to perform by SSA or a
State agency acting in accord with sections 221 or 1633 of the Act.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records are
compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment
of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059, entitled
Earnings Recording and Self-Employment Income System and 60-0089, entitled Claims Folders Systems. Additional
information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
Collection and Use of Information From Your Application - Privacy Act Notice/Paperwork Reduction Act Notice
Paperwork Reduction Act Statement
Form SSA-2-BK (07-2018) UF
Page 7 of 8
(Report AT ONCE if this work pattern changes)
You are confined to a jail, prison, penal institution or
correctional facility for more than 30 continuous days
for conviction of a crime, or you are confined for
more than 30 continuous days to a public institution
by a court order in connection with a crime.
If you become the parent of a child (including an
adopted child) after you have filed your claim, let us
know about the child so we can decide if the child is
eligible for benefits. Failure to report the existence of
these children may result in the loss of possible
benefits to the child(ren).
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.
HOW TO REPORT
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE
MONETARY PENALTIES
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU ANSWER QUESTION 21.
If you are under full retirement age, wife's or husband's benefits cannot be paid for any month before the month in
which you file your claim.
If you are full retirement age or older, wife's or husband's benefits may be payable for some months before the month
in which you file this claim, but not before the month you attain full retirement age.
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 if you receive one or more full benefit payments
prior to the month you attain full retirement age.
Your citizenship or immigration status changes.
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.
(Year)
You can make your reports online, by telephone,
mail, or in person, 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 “my Social Security” 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 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.
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.
Change of Marital Status - Marriage, divorce, and
annulment of marriage. You must report marriage even
if you believe that an exception applies.
You have an unsatisfied warrant for more than 30
continuous days for your arrest for a crime or
attempted crime that is a felony of 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 one year (regardless of the actual
sentence imposed).
Under a special rule known as the Monthly Earnings Test, you can get a full benefit for any month in which you
do not earn wages over the monthly limit and do not perform substantial services in self-employment
regardless of how much you earn in the year. For retirement age beneficiaries this special rule can be used
only for one taxable year which will usually be the year of retirement. For younger beneficiaries such as young
wives and husbands (entitled only by reason of child-in-care), this special rule can be used for two taxable
years. The first taxable year in which the monthly earnings test may be used is usually the first year they are
entitled to benefits. The second taxable year in which the monthly earnings test can be used is always the year
in which their entitlement to benefits stops. In all other years, the total amount of benefits payable will be
based solely on your total yearly earnings without regard to monthly earnings or services rendered in self-
employment.
Any beneficiary goes outside the U.S.A. for 30
consecutive days or longer.
Any beneficiary dies or becomes unable to handle
benefits
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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.)
You have an unsatisfied warrant for more than 30
continuous days for a violation of probation or parole
under Federal or State law.
You become entitled to a pension, an annuity, or a
lump sum payment based on your employment not
covered by Social Security, or if such pension or
annuity stops.
•
Your stepchild is entitled to benefits on your record
and you and the stepchild's parent divorce. Stepchild
benefits are not payable beginning with the month
after the month the divorce becomes final.
•
Form SSA-2-BK (07-2018) UF
Page 8 of 8
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ssa-2-bk APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document