Form SSA-3 Marriage Certification

TOE 120/420

SOCIAL SECURITY ADMINISTRATION

MARRIAGE CERTIFICATION
PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

Form Approved
OMB No. 0960-0009
SEE PAPERWORK/PRIVACY
ACT NOTICE ON REVERSE.
SOCIAL SECURITY NUMBER

I am the spouse of the person named below, who has applied for insurance benefits under Title II of the Social Security
Act, as presently amended.
NAME OF SPOUSE (First Name)
(Maiden Name, if applicable)
(Last Name)
1. Indicate whether your present marriage was performed by:
Clergyman or Authorized Public Official

Other (Explain)

2. Were you married before your present marriage?
Yes

No

(If ''yes'', give the following information about each of your previous marriages.)

PREVIOUS MARRIAGE
TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY:

SPOUSE'S DATE OF BIRTH (or age) GIVE DATE OF DEATH IF SPOUSE
IS DECEASED

Clergyman or Public Official
Other (Explain in "REMARKS")
Spouse's Social Security Number
(If none or unknown, so indicate)

PREVIOUS MARRIAGE
TO WHOM MARRIED

WHEN (Month, Day, Year)

WHERE (City and State)

HOW MARRIAGE ENDED

WHEN (Month, Day, Year)

WHERE (City and State)

MARRIAGE PERFORMED BY:

SPOUSE'S DATE OF BIRTH (or age) GIVE DATE OF DEATH IF SPOUSE
IS DECEASED

Clergyman or Public Official
Other (Explain in "REMARKS")

Spouse's Social Security Number
(If none or unknown, so indicate)
REMARKS: (Use
the reverse
this form for information
about previous
any other marriages,
previous marriages,
(Use this
thisspace
spaceand
of this
form forofinformation
about any other
if necessary)
if necessary)

Form SSA-3 (09-2015) uf (09-2015)
Destroy Prior Editions

Reverse

Page 1

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 WAGE EARNER OR SELF-EMPLOYED PERSON
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)
TELEPHONE NUMBER (Area Code)
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, or Rural Route)
CITY

STATE

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the wage earner or self-employed person must sign below, giving their
full addresses.
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)

Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, [42 U.S.C. 405(a)] authorizes us to collect this information. We
will use the information you provide to help us determine the identity of your spouse. The information you furnish on this
form is voluntary. However, failure to provide the requested information may prevent us from paying benefits to your
spouse.

See Revised Privacy Act Statement Attached

We rarely use the information you supply for any purpose other than for determining the identity of a spouse. 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 Social Security 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 and audit activities necessary to assure the integrity and improvement of Social Security programs (e.g., to the
Bureau of the Census and private entities under contract with us).
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. We use the information from these matching
programs 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.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled Claims
Folders Systems, 60-0089 and Master Beneficiary Record 60-0090. The notices, additional information regarding this
form, and information regarding our systems and programs, are available on-line at www.ssa.gov or at any local Social
Security office.
See Revised PRA Attached
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 5 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY 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 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Form SSA-3 (09-2015) uf (09-2015)

Page 2