Form SSA-4111 (04-2019) UF
Discontinue Prior Editions
Social Security Administration
CERTIFICATE OF ELECTION FOR REDUCED WIDOW(ER)'S AND
SURVIVING DIVORCED SPOUSE'S BENEFITS
Page 1 of 2
OMB No. 0960-0759
(over)
1. Print Name of Wage Earner or Self-Employed Person
(Hereafter called "Worker")
Enter His or Her Social Security Number
2. Print Your Full Name (First name, middle initial, last name)
Enter Your Social Security Number
INFORMATION ABOUT REDUCED WIDOW(ER)'S AND
SURVIVING DIVORCED SPOUSE'S BENEFITS
The law requires that you complete and return this Certificate of Election if you wish to receive a reduced widow's, widower's or
surviving divorced spouse's benefit and are at least age 62 and under full retirement age (FRA).
The following will affect the amount of your benefit:
• The month and year you elect to begin to receive benefits will determine the amount of your monthly payments which will
continue at a reduced rate even after you reach FRA.
• Depending on your date of birth, the rate of reduction applied to your benefit amount can range from 19/40 to 19/56 of
1 percent times the number of months from the start of the reduced benefits until the month you reach FRA.
• If another beneficiary is entitled to a monthly survivor benefit on this Social Security number, your benefit may be reduced
by the total family benefit payable in the month. The benefit paid to a surviving divorced spouse will not affect the benefit
amount paid to other family members who receive benefits on the same record.
INFORMATION ON HOW BENEFITS ARE AFFECTED IF THE DECEASED WORKER RECEIVED REDUCED
RETIREMENT BENEFITS
If the deceased worker received retirement benefits before FRA, the maximum survivor's benefit is limited to the higher amount
that the deceased worker would have received if still alive or 82.5 percent of the deceased worker's unreduced benefit. Because
of this limit, delaying receipt of reduced benefits will not necessarily increase the monthly benefit amount payable. We will review
your selection in item 3 below to make sure that the month selected maximizes your benefit amount.
3. I elect to accept permanently reduced benefits as provided in Section 202(q) of the
Social Security Act, beginning with
The selected month can be the month the deceased worker died or any month before
you reach FRA (provided that the month you choose is within the past 12 months).
MONTH YEAR
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.
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
Telephone Number (include area code)
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State
ZIP Code
Witnesses are required ONLY if this certificate has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person completing this certificate must sign below, giving their full addresses.
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)
