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

TEL

Form Approved
OMB No. 0960-0004

TOE 120/145/155

SOCIAL SECURITY ADMINISTRATION

(Do not write in this space)

APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS*
I apply
all insurance
benefits
I am eligible
Titleyou
II (Federal
Old-Age,
Survivors,
andOld
Disability
With
this for
application,
you are
applyingfor
forwhich
all insurance
benefitsunder
for which
are eligible
under Title
II (Federal
Age,
Insurance)and
and
Part A Insurance)
of Title XVIII
(Health
for the Insurance
Aged andforDisabled)
Social Security
Act, as
Survivors,
Disability
and Part
A ofInsurance
Title XVII (Health
the Aged of
andthe
Disabled)
of the Social
Security
Actamended.
as presently
Theyou
information
youthis
furnish
on this application
will ordinarily
be sufficient
for a
presently
Theamended.
information
furnish on
application
will ordinarily
be sufficient
for a determination
determination
on the
lump-sum
death payment.
on the lump-sum
death
payment.
If*This
you were
as a wife/husband
at the
of yourbenefits
spouse'sunder
death,the
youRailroad
only needRetirement
to completeAct
the and
circled
mayreceiving
also bebenefits
considered
an application
for time
survivors
for
items. All other claimants must complete the entire form.
Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an
*This may also be considered an application for survivors' benefits under the Railroad Retirement Act for Veterans
application for other types of death benefits under title 38). If you were receiving benefits as a wife/husband at the
Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other
time of
ofdeath
your benefits
spouse's
death,
types
under
title you
38). need complete only the circled items. All other claimants must complete the
entire form. For additional information about this application a fact sheet to Form SSA-10-BK is available at
www.socialsecurity.gov.

1. (a) PRINT name of deceased wage earner or
self-employed person (herein
referred to as the "deceased")

FIRST NAME, MIDDLE INITIAL, LAST NAME

X

(c) Enter deceased's Social Security Number

X

X

Male

Female

FIRST NAME, MIDDLE INITIAL, LAST NAME

(b) Enter your Social Security Number
(c) Enter your name at birth if different
from item 2(a)

entire section

X

(b) Check (X) one for the deceased

2. (a) PRINT your name

We revised this

X

FIRST NAME, MIDDLE INITIAL, LAST NAME
X

PART I -- INFORMATION ABOUT THE DECEASED
MONTH, DAY, YEAR
3. Enter date of birth of deceased
X
4. (a) Enter date of death

X

(b) Enter place of death

X

5. Enter name of the State or foreign country where the deceased had a
fixed, permanent home at the time of death.

MONTH, DAY, YEAR
CITY AND STATE

X

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
(b) Enter name(s) of person(s) on whose Social
Security record(s) other application was
filed.

Yes

X

No

(If "Yes," answer
(b) and (c).)

(If "No," go on
to item 7.)

FIRST NAME, MIDDLE INITIAL, LAST NAME
X

(c) Enter Social Security Number(s) of person(s) named in (b).
X

If unknown, check this block

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.
7. (a) Was the deceased unable to work because of illnesses, injuries or
conditions at the time of death?
(b) Enter the date the deceased became unable to work.

X

X

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
X
September 7, 1939 and before 1968?
X

(c) Has anyone (including the deceased) received, or does anyone expect to
receive, a benefit from any other Federal agency?
X
Destroy Prior Editions

No
(If "No," go on
to item 8.)

MONTH, DAY, YEAR

Yes

No

(If "Yes," answer
(b) and (c).)

(If "No," go on
to item 9.)

(Month, year)

(b) Enter dates of service.

Form SSA-10-BK (06-2010) EF (06-2010)

Yes
(If "Yes," answer
(b).)

Page 1

FROM:

(Month, year)
TO:

Yes

No
(Over)

ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS.
Amount
9. (a) About how much did the deceased earn from employment and
self-employment during the year of death?

X

(b) About how much did the deceased earn the year before death?

X

$

Amount
$
No

Yes

10. (a) Did the deceased have wages or self-employment income covered

X

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.

(If "No," answer
(b).)

(If "Yes," skip to
item 11.)

X

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 any increase in my
benefits will be paid with full 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".)
Spouses's Name (including maiden name)

When (Month, Day, and Year)

Where (Name of City and State)

How Marriage Ended

When (Month, Day, and Year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

(or age)

Spouse's Social Security Number (If none or unknown, so indicate)

X

(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)

How Marriage Ended

When (Month, Day, and Year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)

age)

Spouse's Social Security Number (If none or unknown, so indicate)

X

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
Yes
deceased at the time of death or at the time the deceased became disabled (If "Yes," enter the name
X
under Social Security Law?
and address in "Remarks.")
PART II -- INFORMATION ABOUT YOURSELF
14. (a) Enter name of State or foreign country where you were born.

No

X

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
Yes
No
Unknown
X
age 5?
(c) Was a religious record of your birth made before
age 5?
Form SSA-10-BK (06-2010) EF (06-2010)

X

Page 2

Yes

No

Unknown

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)

How Marriage Ended

When (Month, Day, and Year)

Where (Name of City and State)

Marriage performed by:
Spouse's date of birth
Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown, so indicate)

(or age)

Date of death

X

(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)

How Marriage Ended

When (Month, Day, and Year)

Where (Name of City and State)

Marriage performed by:
Spouse's date of birth
Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown, so indicate)

(or age)

If spouse deceased, give date of death

X

(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)

How Marriage Ended

When (Month, Day, and Year)

Where (Name of City and State)

Marriage performed by:
Spouse's date of birth (or age) If spouse deceased, give date of death
Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown, so indicate)

X

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

Yes
X

(If "Yes," skip to item 17.)

(If "No," answer (b).)

(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?
X
Deceased
Surviving spouse
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
X
Social Security benefits, a period of disability under Social Security,
Supplemental Security
Income
supplemental
security
income, or hospital or medical insurance under Medicare?

Yes

No

(If "Yes," answer (b) (If "No," go on
and (c).)
to item 18.)

(b) Enter name of person on whose Social Security record
you filed other application
X
(c) Enter Social Security Number of person named in (b).
X

(if unknown, so indicate)
Form SSA-10-BK (06-2010) EF (06-2010)

Page 3

(Over)

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?
(b) Enter the date you became unable to work.

Yes
X

X

No

(If "Yes," answer
(b) .)

(If "No," go on to
item 19.)

(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?
X

Yes

No

20. Did you or the deceased work in the railroad industry for 5 years or
more?

Yes

No

Yes

No

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?
(b) If "Yes," list the country(ies).

X

(If "Yes,"
answer (b).)

(If "No," go on to
item 22.)

X

22. (a) Have
you
qualified
or expect
do you
expect
qualifyorfor,
a (or
Have you
qualified
for, orfor,
do you
to qualify
for,to
a pension
annuity
a lump sum
place of a(or
pension
or annuity)
based
on your
employment
pension
orinannuity
a lump
sum in
place
of aown
pension
or
and earnings for the Federal Government of the United States, or one of its
annuity)
based on your own employment and earnings for the
States or local subdivisions that was not covered under Social Security?
Federal
Government
ofnot
thegovernment
United States,
or one of its States
(Social Security
benefits are
pensions.)
or local subdivisions? (Social Security benefits are not
government pensions.)
(b)

X

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.

No

Yes

X

(If "Yes," check
which of the items
in item (b) applies
to you.)

(If "No," go
on to item 23.)

I have not applied for but I expect
to begin receiving my pension or
annuity:
(Month, year)
(If the date is not known, enter "Unknown".)

MEDICARE INFORMATION
thisclaim
claim
approved
entitled
to benefits
age
are3within
3 of
months
or could
older automatically
you could
IfIfthis
is is
approved
andand
youyou
areare
still still
entitled
to benefits
at ageat65,
or 65,
you or
areyou
within
months
Age 65oforAge
older65
you
automatically
receive
Part A (Hospital
Insurance)
Medicare
Part B (Medical
at Puerto
age 65.
If you
receive
Medicare
Part AMedicare
(Hospital Insurance)
and Medicare
Part and
B (Medical
Insurance)
coverageInsurance)
at age 65. coverage
If you live in
Rico
or a
foreign
not eligible
for automatic
enrollment
you will
needSecurity
to contact
Security
to request
are notcountry,
eligibleyou
for are
automatic
enrollment
in Medicare
Part in
B,Medicare
you will Part
needB,toand
contact
Social
to Social
request
enrollment.
enrollment.
COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
COMPLETE
ITEM
23cover
ONLY
IF YOU
ARE and
WITHIN
3 MONTHS
OFcovers
AGE 65
ORother
OLDER
Medicare Part B (Medical
Insurance)
helps
doctor's
services
outpatient
care. It also
some
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
will have
to pay a monthly
premium.
The amount
youroutpatient
premium will
be determined
whensome
your coverage
begins.
In
MedicarePart
PartB,Byou
(Medical
Insurance)
helps cover
doctor's
servicesof and
care.
It also covers
other services
that
some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your
Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care.
premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive.
If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when
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
your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the
change in the amount of your premium.
Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you
Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to
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
pay your premiums. You will also get a letter if there is any change in the amount of your premium.
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
youralso
income
wein
receive
from the
Internal Revenue
Service.
You can
enroll
a Medicare
prescription
drug plan
(Part D). To learn more about the Medicare prescription drug plans and
Ifwhen
you have
income
resources, we encourage
to apply for the Extra
Help that is available
to assist you with Medicare
you limited
can enroll
visitand
www.medicare.gov
or callyou
1-800-MEDICARE
(1-800-633-4227;
TTY 1-877-486-2048)
Medicare also
prescription
costs.
The Extra
Helparea
canthat
paycan
the monthly
annual
deductibles
and
prescription co-payments. To learn more or
can tell youdrug
about
agencies
in your
help youpremiums,
choose your
prescription
drug
coverage.
apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.
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.

23. Do you want to enroll in the Medicare Part B (Medical Insurance)?
Form SSA-10-BK (06-2010) EF (06-2010)

Page 4

X

Yes

No

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."
information
*Enter the appropriate monthly limit after reading the instructions,
Work Affects
"How Your Earnings
Affect Your Benefits."

25. (a) How much do you expect your total earnings to be this year?

ALL

NONE
Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

$

(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."

ALL

NONE

*Enter the appropriate monthly limit after reading the
information
Work Affects
instructions,
"How Your Earnings
Affect Your Benefits."

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

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
instructions,
"How Your Earnings
Affect Your Benefits."
Work Affects

ALL

NONE
Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

27. If you use a fiscal year, that is, a taxable year that does not end Month
December 31 (with income tax return due April 15), enter here
the month your fiscal year ends.
X
IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO PAGE 6. 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.

X

(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.

X

(c) I want benefits beginning with
. I understand that either a higher initial payment or a higher
X
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
X
benefits on your own earnings record?
Form SSA-10-BK (06-2010) EF (06-2010)

Page 5

Yes

No
(Over)

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)

I declare
eclare under penalty of perjury that I have examined all the information on this form, and on any accompanying
acco
statements
t
t or forms,
f
and
d it is
i true
t
and
d correctt tto th
the b
bestt off my k
knowledge.
l d
I understand
d t d that
th t 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.
Date (Month, day, year)

SIGNATURE OF APPLICANT

Telephone number(s) at which you
may be contacted during the day

Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE

X

FOR
OFFICIAL
USE ONLY

__ __ __

AREA CODE

Direct Deposit Payment Address (Financial Institution)
Routing Transit Number

C/S

Depositor Account Number

No Account

Moved this entire section above the penalty statement

Direct Deposit Refused

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

2. Signature of Witness

Address (Number and street, City, State and zip Code)

Address (Number and street, City, State and zip Code)

Form SSA-10-BK (06-2010) EF (06-2010)

Page 6

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS
BEFORE YOU RECEIVE A
NOTICE OF AWARD

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING AFTER YOU RECEIVE A
TO REPORT
NOTICE OF AWARD

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.
CLAIMANT

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.

DECEASED'S SURNAME IF
DIFFERENT FROM CLAIMANT'S

SOCIAL SECURITY CLAIM
NUMBER

PRIVACY ACT NOTICE
Collection and Use of Personal Information

See Revised Privacy Act Statement Attached

Sections 202, 205 and 223 of the Social Security Act, as amended, authorize us to collect the information
requested on this form. The information you provide will be used to make a decision on this claim. Your response is
voluntary. However, failure to provide the requested information may prevent an accurate and timely decision on any
claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining entitlement to Social
Security benefits. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the
information provided on this form in accordance with approved routine uses which include, but are not limited to, the
following: 1. To enable an agency or third party to assist Social Security in establishing rights to Social Security
benefits and/or coverage; 2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State and local level; 3. To comply with Federal laws requiring the disclosure of the
information from our records; and 4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer matching programs
compare our records with those of 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 for this information is contained in our System of Records Notice 60-0089 (Claims
Folders Systems). Additional information regarding this form and other systems of records notices and Social
Security programs are available from our Internet website 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 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 REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, THE
NEAREST U.S EMBASSY OR CONSULATE 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
1-800-772-1213 (TTY 1-800-325-0778) for the address. You may send comments on our time estimate above to: SSA, 6401
Security Boulevard, Baltimore, MD 21235-6401.
0001. Send only comments relating to our time estimate to this address, not the
completed report.
Form SSA-10-BK (06-2010) EF (06-2010)

Page 7

(Over)

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
X

X You
have
an unsatisfied
warrantorfor
a violation
You are
violating
a condition of probation
parole
imposed

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.)

Disability Applicants

X

Your citizenship or immigration status changes.

X

You go outside the U.S.A. for 30 consecutive days or
longer.

X

Any beneficiary dies or becomes unable to handle
benefits.

X

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.)
X

Change of Marital
--Marriage,
divorce,
of marriage.
You
Change
of Status
Marital
Status
- annulment
Marriage,
divorce,
must report a change
in marital status
believe
that an exception
annulment
of marriage.
You even
mustif you
report
marriage
even
ifapplies.
you believe that an exception applies.

X

You
confined
for more than
30 continuous
to jail, institution
prison, penal or
Youareare
confined
to jail,
prison,days
penal
institution,
or correctional
for conviction of
of aacrime
or you
correctional
facility facility
for conviction
crime
orare
you are
confined
to a public
order in connection
with aorder
crime. in
confined
to ainstitution
publicby court
institution
by court

connection with a crime.
X

X

X

of

probation
under Federal or State law.
under Federalororparole
State law.

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 government pension or annuity
(from the Federal government or any State or any
political subdivision thereof) or your pension or annuity
amount changes.
You
an unsatisfied
arrest warrant
for morefor
thanyour
30 continuous
Youhave
have
an unsatisfied
warrant
arrest days
for for
a
flight to avoid prosecution or confinement, escape from custody, or flightcrime or attempted crime that is a felony (or, in
escape.

jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment for a
term exceeding 1 year.)

1. You return to work (as an employee or selfemployed) 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 and15 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.
HOW TO REPORT
You can
make
your reports
telephone,
in person, or
online,or in
You
can
make
your by
reports
by mail,
telephone,
mail,
whicheverwhichever
you prefer. you prefer.
person,
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

X

Calling
us TOLL FREE at 1-800-772-1213;
www.socialsecurity.gov;

X

IfIf you
youare
are
deaf or hearing impaired, calling us TOLL
deaf of hearing impaired, calling us TOLL FREE at TTY
FREE
at
TTY
1-800-325-0778; or
1-800-325-0778; or

Calling us TOLL FREE at 1-800-772-1213;

X

Calling, visiting or writing your local Social Security office shown at
Calling,
visiting or writing your local Social Security
the
phone
numberat
and
address
on your
claim receipt.
office
shown
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 earnings both before and after retirement, 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 month 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:
X

YOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR.

(Forthe
theappropriate
appropriate
exempt
amount,
seeWork
"How
Your
Earnings
Affect Your Benefits.")
(For
exempt
amount,
see “How
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 if you receive one or more full benefit payments prior to the month you attain full retirement
age.
Form SSA-10-BK (06-2010) EF (06-2010)

Page 8

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
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 make a decision on this claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed, or could result in
loss of benefits.
We rarely use the information you supply us for any purpose other than to determine entitlement
to Social Security benefits. 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, Claim Folders System, 60-0089. 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.