Application for Widow's or Widower's Insurance Benefits - Paper Version

Form Approved
0MB 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
0

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ii,.Su-t-

You change your mailing address for checks(or
residence. (To avoid delay in receipt of check~ ou
should ALSO file a regular change of address
notice with your post office.)

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Your citizenship or immigration status changes.

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

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Any beneficiary dies or becomes unable to handle
benefits.

l01Mltf.\..• You begin to receive a pension, annuity, or a lump
sum payment based on your government
employment not covered by Social Security or your
pension or annuity amount changes or stops.
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You have an unsatisfied warrant for more than 30
continuous days for your arrest for a crime or
attempted crime that is a felony or flight to avoid
prosecution or confinement, escape from custody,
and fl ight-escape. In most jurisdictions that do not
classify crimes as felonies, this applies to a crime
that is punishable by death or imprisonment for a
term exceeding 1 year (regardless of the actual
sentence imposed).

WORK AND EARNINGS
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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 O(are)O (are not) self- employed rendering
substantial services in your trade or business.
(Report AT ONCE if this work pattern changes)

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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.

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 selfemployment 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 on line, whichever you prefer.
If you are awarded benefits, and one or more of the
above change(s) occur, you should report by:

0v,.,;~ S-Sv:c.,e~

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Visiting the section "WR-et ¥e1:,1 Gan Qg 0olio~ at our
website at www.socialsecurity.gov

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Calling us TOLL FREE at 1-800-772-1213; If you are
deaf or hearing impaired, calling us TOLL FREE at
TTY 1-800-325-0778; or

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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.

D

We are returning the documents you submitted with this claim.

Form SSA-10-INST (04-2017) UF
Destroy prior editions

(OVER)

Privacy Act Statement
See Revised Privacy Act
Collection and Use of Personal Information

Statement Attached

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 determine eligibility of you or a dependent for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us w ith all or part of the information may prevent
an accurate and timely decision on your entitlement or a dependent's entitlement to Social Security benefit payments.
We rarely use the information you supply us for any purpose other than for making a determination relating to your
entitlement or a dependent's entitlement to Social Security benefit payments. However, we may use it for the
administration and integrity of Social Security programs. 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 record s
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,
Master Beneficiary Record, 60-0090. 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 secti on 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. The 0MB control number for this
collection is 0960-0004. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to SSA, 6401 Security Blvd.
Baltimore, MD 21235-6401.

Form SSA-10-INST (04-2017) UF

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(e) and 202(f) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide us with all
or part of the information could prevent us from making an accurate and timely decision on your
entitlement for widow or widower benefits.
We will use the information to make a determination for entitlement to widow or widower
benefits. We may also share your information for the following purposes, called routine uses:


To contractors and other Federal agencies, as necessary, for assisting Social Security
Administration (SSA) in the efficient administration of its programs. We contemplate
disclosing information under this routine use only in situations in which SSA may enter a
contractual or similar agreement, with a third party to assist in accomplishing an agency
function relating to this system of records; and



To third party contacts, especially in situations where the party to be contacted has, or is
expected to have, information relating to the individual’s capability to manage his/her
affairs or his/her eligibility for or entitlement to benefits under the Social Security
program; when the data are needed to establish the validity of evidence; to verify the
accuracy of information presented by the individual and, if it concerns his/her eligibility
for benefits under the Social Security program.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 60-0090 entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of all our
SORNs, is available on our website at www.ssa.gov/privacy.