Current SSA-10-BK

SOCIAL SECURITY ADMINISTRATION

TEL

Form Approved
OMB No. 0960-0004

TOE 120/145/155

(Do not write in this space)

APPLICATION FOR WIDOW'S OR WIDOWER'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. The information you furnish on this application will ordinarily be sufficient for a determination
on the lump-sum death payment.
*This may also be considered an application for survivors benefits under the Railroad Retirement Act and for
Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an
application for other types of death benefits under title 38). If you were receiving benefits as a wife/husband at the
time of your spouse's death, you 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
u

(b) Check (X) one for the deceased

u

(c) Enter deceased's Social Security Number

u

2. (a) PRINT your name

u

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)

Male

u

FIRST NAME, MIDDLE INITIAL, LAST NAME
u

PART I -- INFORMATION ABOUT THE DECEASED
MONTH, DAY, YEAR
3. Enter date of birth of deceased
u
4. (a) Enter date of death
(b) Enter place of death
5. Enter name of the State or foreign country where the deceased had a
fixed, permanent home at the time of death.

u

MONTH, DAY, YEAR

u

CITY AND STATE

u

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

u

No

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

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

FIRST NAME, MIDDLE INITIAL, LAST NAME
u

(c) Enter Social Security Number(s) of person(s) named in (b).
If unknown, check this block

u

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.

u

u

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
u
September 7, 1939 and before 1968?
u

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

u

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

u

$

Amount
$
No

Yes

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

u

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.)

u

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)

u

(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)

u

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
u
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

u

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
u
age 5?
(c) Was a religious record of your birth made before
age 5?
Form SSA-10-BK (06-2010) EF (06-2010)

u

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

u

(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

u

(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)

u

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
u

(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?
u
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
u
Social Security benefits, a period of disability under Social Security,
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
u
(c) Enter Social Security Number of person named in (b).
(if unknown, so indicate)
Form SSA-10-BK (06-2010) EF (06-2010)

u

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
u

u

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?
u

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).

u

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

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

u

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

u

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

u

(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
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
are not eligible for automatic enrollment in Medicare Part B, you will need to contact Social Security to request enrollment.

COMPLETE ITEM 23 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 doesn't 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.
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 also
can tell you about agencies in your area that can help you choose your prescription drug coverage.
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

u

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

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.
u
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.

u

(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.

u

(c) I want benefits beginning with
. I understand that either a higher initial payment or a higher
u
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
u
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 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 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

u

FOR
OFFICIAL
USE ONLY

__ __ __

AREA CODE

Direct Deposit Payment Address (Financial Institution)
Routing Transit Number

C/S

Depositor Account Number

No Account
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
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. 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
u

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.)

u

Your citizenship or immigration status changes.

u

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

u

Any beneficiary dies or becomes unable to handle
benefits.

u

u

Disability Applicants

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.)
u

u

Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report marriage even
if you believe that an exception applies.
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you are
confined to a public institution by court order in
connection with a crime.

u

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.

u

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.

u

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

You have an unsatisfied warrant for your arrest for a
crime or attempted crime that is a felony (or, in
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 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:
u

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

u

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

u

Calling, visiting or writing your local Social Security
office shown at 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:
u

YOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR.

(For the appropriate exempt amount, see "How Your Earnings Affect 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