SSA-10-INST (instructions)

Form Approved
OMB No. 0960 - 0004

Social Security Administration

REPORTING RESPONSIBILITIES FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT
MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES
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.)
Your citizenship or immigration status changes.

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

You begin to receive a government pension or
annuity (from the Federal government or any State
or local subdivision thereof) based on your own
employment and earnings that was not covered
under Social Security, or your pension or annuity
amount changes.
You have an unsatisfied arrest warrant for more than
30 continuous days for flight to avoid prosecution or
confinement, escape from custody, or flight escape.
You are violating a condition of probation or parole
imposed under Federal or State law.

Any beneficiary dies or becomes unable to handle
benefits.

Work Changes - On your application you told us
you expect total earnings for
to be $
a month.
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)
Change of Marital Status - Marriage, divorce,
annulment of marriage. You must report a change in
marital status even if you believe that an exception
applies.
Custody Change or Disability Improves - Report if a
person for whom you are filing, or who is in your
care dies, leaves your care or custody, changes
address, or, if disabled, the condition improves.
You are confined for more than 30 continuous days
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.

WORK AND EARNINGS
For those under full retirement age, the law requires that
a report of earnings be filed with SSA within 3
months and 15 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, in
person, or online, whichever you prefer.
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
website at www.social secuirty.gov;
Calling us TOLL FREE at 1-800-772-1213; If you are
deaf or hearing imparied, calling us TOLL FREE at
TTY 1-800-325-0778; or
Calling, visiting or writing your local Social
Security office at the phone number and address
shown on your claim receipt.
For general information about Social Security, visit
our web site at www.socialsecurity.gov.

NOTICE ABOUT DOCUMENTS
We recommend that you keep copies of all documents you submitted to us.
We are returning the documents you submitted with this claim.
Form SSA-10-INST (04-2014) EF (04-2014)
Destroy prior editions

(OVER)

Privacy Act Statement
Collection and Use of Personal Information

Section 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 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 our 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 our 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
Claims Folders Systems, 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.

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, 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 Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to
this address, not the completed form.

Form SSA-10-INST (04-2014) EF (04-2014)