Application for Widow's or Widower's Insurance Benefits

OMB 0960-0004

SSA needs information to make a formal determination for entitlement to widow(er)’s benefits. We use Form SSA-10-BK to determine whether an applicant meets the statutory and regulatory conditions for entitlement to widow(er)’s Title II benefits. SSA employees interview individuals applying for benefits either face-to-face or via telephone, and enter the information on the paper form, or into the Modernized Claims System (MCS) and the Preliminary Claims System (PCS). The respondents are applicants for Widow(er)’s Insurance Benefits.

The latest form for Application for Widow's or Widower's Insurance Benefits expires 2022-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-10 Application for Widow's or Widower's Insurance Benefits - Paper Version Form
Supporting Statement - 0004 (Final).docx Supporting Statement A
Addendum - 0004 (Final).docx Supplementary Document
Application for Widow's or Widower's Insurance Benefits - Paper Version Form
Application for Widow's or Widower's Insurance Benefits - Modernized Claims System (MCS) Other-MCS Screens

All Historical Document Collections

202202-0960-007 Approved without change	Revision of a currently approved collection	2022-06-01
201810-0960-018 Approved without change	Revision of a currently approved collection	2019-02-26
201612-0960-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-12-16
201512-0960-002 Approved without change	Revision of a currently approved collection	2016-02-24
201409-0960-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-09
201211-0960-002 Approved without change	Revision of a currently approved collection	2013-03-11
200909-0960-005 Approved without change	Revision of a currently approved collection	2009-12-08
200805-0960-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2008-05-19
200609-0960-025 Approved with change	Extension without change of a currently approved collection	2006-09-25
200608-0960-018 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-09-01
200310-0960-011 Approved without change	Extension without change of a currently approved collection	2003-10-31
200212-0960-011 Approved without change	Revision of a currently approved collection	2002-12-23
199911-0960-005 Approved without change	Reinstatement with change of a previously approved collection	1999-11-08
199909-0960-008 Approved without change	No material or nonsubstantive change to a currently approved collection	1999-09-23
199608-0960-007 Approved without change	Extension without change of a currently approved collection	1996-08-16
199307-0960-006 Approved without change	Extension without change of a currently approved collection	1993-07-26
199005-0960-006 Approved without change	Revision of a currently approved collection	1990-05-14
198908-0960-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-08-25
198706-0960-002 Approved without change	Revision of a currently approved collection	1987-06-23
198409-0960-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-09-26
198408-0960-003 Approved without change	Revision of a currently approved collection	1984-08-15
198302-0960-009 Approved without change	Revision of a currently approved collection	1983-02-28
198209-0960-003 Approved without change	Revision of a currently approved collection	1982-09-29
198110-0960-005 Approved without change	Revision of a currently approved collection	1981-10-02
198009-0960-004 Approved without change	Revision of a currently approved collection	1980-09-09
197912-0960-003 Approved without change	Revision of a currently approved collection	1979-12-21
197909-0960-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1979-09-28
197809-0960-015 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-09-28
197807-0960-006 Approved without change	Revision of a currently approved collection	1978-07-26
197804-0960-019 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-04-07
197711-0960-013 Approved with change	No material or nonsubstantive change to a currently approved collection	1977-11-30

OMB Details

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-10-BK

Application for Widow's or Widower's Insurance Benefits

Fillable Printable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.