SSA-2 Application for Wife's or Husband's Insurance Benefits

0960-0618

Part C added to
#6; updated the
instruction for
the answer

(c) when were you lawfully admitted to the U.S.?

sections of
Parts A & B

Instruction deleted

Statement added to #15

I agree to promptly notify the Social Security Administration if I become entitled to a pension or annuity based on my
employment not covered by Social Security, or if such pension or annuity stops.

Continuation of Page 3

Revised #17

Revised #18

Revised #22

Modified "Medicare Information" section

Deleted #'s 25 & 26

Updated Privacy Act Statement

See Revised PRA Attached

See Revisions on the Next Page

Modified Section

Added Bullet

Added Bullet

Updated Section

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 control number. We estimate that it will take about 15
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 1800-325-0778). 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.