Form SSA-10-BK Application for Widow's or Widower's Insurance Benefits

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Federal Gavernment of thm lJnikd &tm, or on# of Ita S W m

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YUU RECElVE A
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QUESTION OR #METHINO
TO REPORT

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NOTICE OF AWARD

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recaived end wM tw ~ ~ t mascq
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Your applleation for %&I

You Iltrould hew from us MtMn
after
you have gRrsrn #a MI tha thainfomlalm we requastad.
Somi Jslmm y taka longor If addltlwral hfomratlm

Is e.

In the mentimu, H y w &mge yow arkJrm, or If
thwekwmrrOffhW~ethmtrnll)rmffectw~
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for you-jhordd repolT the
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gha ue yaw dlkn nurnbr when
p u p 8.
W p i d n g w ~ ~ Y W r ~ .
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bsglsdwmm.

The S d a l Sewthy AdminlsttakDn is a d w k d to
edlm r)re InfomsrceiPn on thh fmm u m h cwtkrw
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and a 3 d tt#l s&d
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monthly benefb. Vw do not htu give uo thu
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requrned tnfmmtkn. How-,
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the informadux we w#l bg u m k tu make m #WWand rimsly M e i o n conr;atnhp y o w bntitknwnt w r
end other ressonr why
dopandent's rnttdrrnanr to benbjlt payments,
~ w u ~ ~ k u O e d f f ~ o u t a r s
nn#lblr Ih %aid Seurftv offbaa. H y9u want ta
The Informdm you pmvidd may k d i d o a d to
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my S d d &curb
another Fadaral, Stwe or laad gLwwr#nmt * g w y for
daurmidng

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F ~ m y o u r b a h ( t , t o n ~ p * * ~
p4lrfwmana trt -h
mnd stdmihl -I-,
ar 70
thQ Depwsnmt of J d a for rw9 In repr*osnting t)w

Federal g u v ~ m t .

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FPILURE M REPORT MAY m U L T Ihl OVERPAYMW THAT MUST BE REPAID, A
m IN WSSIBLE MONETARY PENALTtES

You chwgs your m d h g addrsas for checkp w
of -8
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You
a

haw an ununtlaflsd warrant fw your rrrent tor

or attempted adma t b t io f h y (or, In
~ l p o u ~ ~ ~ s u a ~ s ~ g ~ ~ ~ tjurkddmw
- d a d that
t ~do not defkre crlmea w felonies, e
r;rlrna that Is punlhaMa by death or Imprlmmmt
whh y w r pust offke.1

You go outside the U.S.A.
or longsr-

tw SO w w c u t i v e dsya

Any bensfiiiaty dies w bwomes u d d e to

handle

benefits.
Work Change*

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than 8

0 lare notJ naming wagm of

On your appllEetCon you tnld us
y w mpwt tots! psmlngr tor
t o bg

1 , Yw return to work I# mn mmployee or n l f imp!owdI
of mmmt of earnings.

can make ywr rspwts by tat-,
mail, or In
psrm. wwdmvw you w e b .
ll ywl srs s w d bmfb, and one w more of tlw
~ r u % n o t ) d ~ m p l o Y q d ~a b M ~ - , y o u g h O U ( d n e # t b y :

e month.

0 (ertll O
substentla1 wwtcga
Yw

more

for s twm e x c d l n g 1 w.1
You h w e an u n o r M M warrant for rr vlolrtton of
proMLon Qt fm& under M w a t or 8Law.

You

in your tradr or m.

(Report AT ONCE if tMr wbrk pamm chnnw,l

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Change of Marital Otutu#
Manisga, dlwrcs,
anmllmanx of marrlwa. Yw m w
evm If you Wirw W a mn waeptlon appkr.

are eonfind to jail, m n , penal i m h t i o n oc
corrcrodml facility far omvictim of a erkne or yw
lrre mnfhd to s publlc hmtitution by c w r t wdec in
-oc
with r crime.
You

CCMmdyChangs-R~ifapmmfwwhomyou
an, filing, or who i u k r y o u u a m d b . h v u a v o u r
care or ~ s t a d yor
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w.

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You bqin to r e d w 8 government pen&
or
annuhy {from W F.dsrel gwemmsnt or any 8Wta
or any ps#tkal subdMsbm thereof) or your p s m n
or a m i w mount ch-.

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full ratiremsm sgs, the b w requlm
of mrnw be Nled with SSA witMn 3
n w & m m d l 6 d n y 6 ~ t h a s n d o f enytmxablsyet~r

For tham

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InWMbyouerwnmore~thssnMlal~xemPt
mlmm. Ysu msy
SSA to t#6 a wpm.
Oahawkn,8eAwfU~~Qarnlrvee~bYyour
mmlpwedd #Id v d - m l l b m #M mm Cft
mp@bmMlea the report of iwmhgs re&&
by lrrvv
a n d s d k u t b m p r t a s m h r t h s ~ r z s a t . ttisycnrr
rwp&Wytosnswe thst ttss h f o m d m
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rPonor#nk'lgy#~dlwuhcon%d. Youmuntfwrdsr

ddsllor#sln-

4-

k not

your r d .

YOU Wfll EARN OVER W E EXEMPT AMOWT T M YEAR.

{Far the ~ppmpriateexempt amount, wtr "How Y w r Emrnlngl A f b t Your m f i U . ' )

ae r w d d w h your -fit
wmt basad on the caarninga on