Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)

SSA will insert the following revised PA Statement into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(e), (f) and (q) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination regarding your
eligibility for reduced benefits as a widow(er) or surviving divorced spouse.
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.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0089, entitled Claims Folders Systems. Additional
information about this and other system of records notices and our programs is available online
at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide 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
incorrect payments or delinquent debts under these programs.