Form SSA-1-BK, Application for Retirement Benefits Instructions

Enter any additional explanations or comments to clarify your answers on this application. This field is optional—complete only if you have further information to provide. Type your remarks here; if you need more space, attach a separate sheet labeled “Remarks.”

Enter the official name and mailing address of the Social Security Administration office that received your retirement insurance benefits claim. Use the office designation followed by street address, city, state, and ZIP code. Complete this field once the SSA office assignment is known.

Enter the number of days within which you should hear from the Social Security Administration after you have provided all requested information. Use only numeric digits (for example, 30).

Enter the month (MM) when you became, or expect to become, eligible for a pension or annuity based on your work after 1956 not covered by Social Security. Complete this field only if you answered “Yes” to 12(a) Are you entitled to, or do you expect to be entitled to, a pension or annuity based on your work after 1956 not covered by Social Security? Use two-digit format (01–12).

Enter the four-digit year (YYYY) when you became eligible, or expect to become eligible, for a pension or annuity based on your work after 1956 not covered by Social Security. Only required if you answered “Yes” to “Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security?”.

Enter the two-digit month (01–12) when you became, or expect to become, entitled to a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security. Only complete this field if you answered 'Yes' to question 12(a) Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security.

Enter the four-digit year in the “I became entitled, or expect to become entitled, beginning – YEAR” field. Only complete this field if you selected Yes for question 12(a) Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security. Enter year as YYYY.

Check this box if you want your retirement benefits to start at the earliest possible month even though doing so will permanently reduce your monthly amount based on your age.

Check this box if you are or will reach full retirement age within the next 12 months and wish to start retirement insurance benefits at the earliest possible month without any permanent reduction to your ongoing benefit amount.

Select this option when you want to specify the exact month your retirement benefits should start by entering that month on the provided blank rather than accepting the earliest possible or full retirement–age start dates.

Enter the month and year you want your retirement insurance benefits to begin (for example, “July 2024”). Complete this field only if you selected 23(c) “I want benefits beginning with ______.” Format with the full month name followed by the four-digit year.

In the fourth box in the CHANGES TO BE REPORTED AND HOW TO REPORT section, mark an X if any beneficiary dies or becomes unable to handle benefits. Leave blank if not applicable.

Check this box if the applicant is a U.S. citizen.

Check this box if you are an alien who is lawfully present in the United States.

Check this box if you are not a United States citizen.

Check this box if you are not an alien lawfully present in the United States.

If you answered “Yes” to Are you an alien lawfully present in U.S.?, enter the date you were lawfully admitted to the United States in Month, Day, Year format (e.g., April 15, 2005). Otherwise, leave this field blank.

If you selected “Yes” for question 11(a) (“Do you (or your spouse) have Social Security credits under another country’s Social Security system?”), enter the full name of each country where those credits apply. Separate multiple country names with commas and spell out each country name in full.

Enter the claimant’s full legal name (first, middle initial, last). Required.

Enter the date the Social Security Administration received your retirement insurance benefits claim in MM/DD/YYYY format.

Enter the applicant’s mailing address: number and street name, Apt No., P.O. Box, or Rural Route. Do not enter city, state, or ZIP Code here. If the residence address differs, enter it in the “Remarks” section.

Enter the city and state for your Applicant’s Mailing Address. Type the full city name, followed by a comma and a space, then the standard two-letter USPS state abbreviation (for example, “Los Angeles, CA”). This field is required.

Enter the five-digit ZIP Code for your Applicant’s Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route). Include all five digits without spaces or hyphens. This field is required for all applicants.

Enter the telephone number, including area code, where you can be reached if you have a question or something to report after you receive your notice of award. Use the format XXX-XXX-XXXX (three-digit area code, three-digit prefix, four-digit line).

Enter the U.S. telephone number(s) where SSA can reach you if you have a question or need to report something before you receive your Notice of Award. Use 10-digit format with hyphens (area code-prefix-line, e.g., 123-456-7890). If you have more than one number, separate each with a comma.

Enter the date your current marriage began in MM/DD/YYYY format (e.g., 07/12/2010). Required only if you are currently married; otherwise leave this field blank.

Required if this marriage has ended. Enter the month, day, and year the marriage ended in MM/DD/YYYY format (for example, 06/15/2000). Leave this field blank if the marriage is still in effect.

If you have an additional marriage to report under “Enter information about any other marriage,” enter here the date that marriage began in Month, day, year format (for example, March 15, 1990). If no additional marriage applies, write “None” in the “Spouse’s name (including maiden name)” field.

Sign your full legal name (First Name, Middle Initial, Last Name) in ink. This field is required for your application.

Enter the date you sign this form using numeric month, day, and four-digit year in MM/DD/YYYY format (e.g., 11/30/2022). This field is required when submitting the form.

Enter the full legal name (first name, middle initial, last name) of your first unmarried child (including adopted children and stepchildren) or dependent grandchild who is under age 18; or age 18–19 and attending secondary or elementary school full-time; or disabled (disability began before age 22). If you have no such children or dependent grandchildren, type "NONE".

Enter the full legal name (first name, middle initial or middle name if any, and last name) of your second unmarried child or dependent grandchild who meets the criteria listed in 15. Only complete this field if you have a second eligible child; otherwise leave it blank.

Enter the full legal name (first name, middle initial, and last name) of your third unmarried child (including adopted children, stepchildren, or dependent grandchildren) who meets the criteria listed in Item 15. If you do not have a third child meeting those criteria, enter NONE, then proceed to Item 16.

Enter the full legal name (first name, middle initial, last name) of your fourth unmarried child (including adopted children and stepchildren) or dependent grandchild (including stepgrandchildren) as described in Item 15. If you have fewer than four such dependents, leave this field blank.

Enter the full legal name (first, middle initial, last) of your first unmarried child—including adopted children, stepchildren, or dependent grandchildren—who is now or was in the past 6 months either under age 18; age 18 to 19 and attending secondary or elementary school full-time; or age 18 or over with a disability that began before age 22, as required by Item 15’s “List below FULL NAME OF ALL your children …” section. If you have no such children, enter “NONE.”

Enter the full legal name (first name, middle initial(s), and last name) of your second child or dependent grandchild who is now or was in the past 6 months unmarried and meets the criteria listed in Item 15 (under age 18; age 18–19 attending elementary or secondary school full-time; or disabled with disability beginning before age 22). Complete this field only if you have a second such child or dependent grandchild; otherwise leave it blank.

Enter the full legal name (first name, middle initial, last name, suffix if any) of your third unmarried child or dependent grandchild. If you have fewer than three children or dependent grandchildren that meet the eligibility criteria on this form, leave this field blank.

Enter the full legal name (first, middle initial, last name, suffix if applicable) of your eighth unmarried child or dependent grandchild who meets the criteria listed in Item 15 (under age 18; age 18–19 and attending secondary school or elementary school full-time; disabled with disability onset before age 22; or age 18–23 and in full-time post-secondary attendance). Only complete this field if you have eight such children; if you have fewer than eight, leave it blank; if you have no eligible children, write “NONE” in the first field under Item 15 and proceed to Item 16.

If you are completing Direct Deposit Payment Information (Financial Institution), enter the nine-digit routing transit number assigned by your bank for direct deposit, including any leading zeros. Enter all nine digits without spaces or hyphens. Leave blank if you are not using direct deposit.

Enter the numeric account number for the bank account you selected under “Checking” or “Savings” in the Direct Deposit Payment Information (Financial Institution) section. Provide all digits exactly as they appear on your deposit slip or bank statement, without spaces or hyphens. Required if you check “Checking” or “Savings”; leave blank if you check “Enroll in Direct Express” or “Direct Deposit Refused.”

Check this box when you want your retirement insurance benefits paid directly into your savings account.

Check this box to have your retirement insurance benefits deposited into the checking account you provided at your financial institution.

Check this box if you do not wish to have your retirement benefit payments made by direct deposit.

Check this box if you want your retirement insurance benefits paid through the Direct Express prepaid debit card program instead of a bank account deposit.

Check this box if your net earnings from your trade or business last year were $400 or more.

Check this box if, for last year, your net earnings from your self-employment were less than $400.

Enter the total dollar amount of all wages and self-employment income you received in the previous calendar year. Use whole dollars only—enter numerals without the dollar sign, commas, or cents. If you had no earnings last year, enter 0.

Check this box if you did not have any months last year that qualify as exempt because in every month you either earned above the threshold or performed substantial self-employment services.

Check this box if every month of last year was exempt because you did not earn over the wage limit and performed no substantial self-employment services.

Check this box if, for January of the preceding year, you did not earn more than the allowable monthly wage limit and did not perform substantial self-employment services, making that month an exempt month.

Check this box if for May of last year you did not earn more than the applicable monthly limit and did not perform substantial self-employment during that month.

Check this box if in September of last year you did not earn more than the allowable monthly limit and did not perform substantial self-employment, making that month exempt.

Check this box if in October of last year you did not earn more than the applicable monthly earnings limit and did not perform substantial self-employment services, making October an exempt month.

Check this box if June of last year was an exempt month in which you did not earn more than the allowable monthly limit in wages and did not perform substantial self-employment services.

Check this box if in February of last year you did not earn more than the monthly earnings limit and did not perform substantial services in self-employment, making it an exempt month.

Check this box if you did not earn more than the applicable monthly limit and did not perform substantial self-employment during November of last year, designating it as an exempt month.

Check this box if, in July of last year, you did not earn more than the allowable monthly wage limit and did not perform substantial services in self-employment.

Enter the monthly earnings limit, in whole dollars, that you do not expect to exceed in wages (and self-employment) for next year to count each month as exempt under part 21(b). Determine the correct limit from the instructions “How Work Affects Your Benefits.” Complete this field only if you are now in the last four months of your taxable year (September–December for a calendar year). Enter only numerals—do not include a dollar sign, commas, or cents.

Enter the monthly earnings threshold (in whole U.S. dollars) that qualifies a month as exempt for Item 20(b), per the SSA instructions titled “How Work Affects Your Benefits.” Include only the numeric dollar amount (no commas or cents).

Enter the date you became unable to work in MM-DD-YYYY format. Complete this field only if you checked “Yes” for 9(a) Are you, or during the past 14 months have you been, unable to work because of illnesses, injuries or conditions?

Check this box if you have not been unable to work due to illnesses, injuries, or conditions within the past 14 months.

Check this box if you currently are, or during the past 14 months have been, unable to work because of illnesses, injuries, or other conditions.

Check this box if neither you nor your spouse (or prior spouse) worked in the railroad industry for at least five years.

Check this box if you or your spouse (or prior spouse) has worked in the railroad industry for at least five years.

Enter the four-digit year in which your work ended for the second employer (YYYY). If you are still working for this employer, enter “Not Ended.”

Enter the four-digit year in which your employment ended for the third employer listed under Item 17. Complete this field only if you have listed a third employer under Item 17. If you are still employed by that employer, enter "Not Ended."

Enter the kind of trade or business in which you were self-employed (for example, storekeeper, farmer, physician). Complete this field only if you checked “Yes” to “Were you self-employed this year and/or last year?” in item 18(a).

If you checked “Last Year” in Item 18(b), enter the kind of trade or business in which you were self-employed last year (for example, storekeeper, farmer, physician).

Enter the four-digit year when your work ended with the fourth employer you listed under NAME AND ADDRESS OF EMPLOYER in item 17. If you are still employed by that employer, enter "Not Ended". Leave blank if you did not list a fourth employer.

Enter the two-digit month (MM) when work ended with the fourth employer listed under “NAME AND ADDRESS OF EMPLOYER” in Item 17. If you are still working for this employer, enter “Not Ended.” If you did not list a fourth employer, leave this field blank.

Enter the four-digit year (YYYY) in which you began working for the fourth employer listed under NAME AND ADDRESS OF EMPLOYER. Complete this field only if you have provided a fourth employer; otherwise leave it blank.

Enter the two-digit month (01 through 12) in which you began work for the fourth employer listed under “NAME AND ADDRESS OF EMPLOYER” in Item 17. Complete this only if you have entered a fourth employer; otherwise leave this field blank.

Enter the full legal name and mailing address (street, city, state, ZIP code) of the fourth person, company, or government agency for whom you worked this year, last year, or the year before last. Complete this field only if you have a fourth employer; otherwise leave it blank or provide additional details under “Remarks.”

Check this box if you did not have any wages or self-employment income covered under Social Security for every year from 1978 through the year before this application.

Check this box if you had wages or self-employment income covered under Social Security for every year beginning in 1978 through last year.

Check this box if you were not self-employed during this year or last year to skip ahead to the next question.

Check this box if you were self-employed in the current year or the previous year so you can answer the follow-up questions about your self-employment.

Check this box if your net earnings from self-employment this year were less than $400.

Check this box if your net earnings from self-employment this year were $400 or more.

Check this box if in March of last year you did not earn more than the specified monthly wage limit and did not perform substantial services in self-employment, making that month exempt.

Check this box if in December of last year you did not earn more than the applicable monthly earnings limit and did not perform substantial self-employment services, making December an exempt month.

Check this box if you did not earn more than the specified monthly wage limit and did not perform substantial self-employment in August of last year, making it an exempt month for your benefit calculation.

Check this box if in April of last year you did not earn more than the applicable monthly wage limit and did not perform substantial self-employment services, designating April as an exempt month.

Enter the maximum monthly wage amount (in dollars) used to determine which months qualify as exempt months in Item 19(b). Only enter the numerals (the dollar sign is already printed); do not include commas. You may enter cents with two decimal places if needed (for example, 1650 or 1650.00). This field is required if you are marking exempt months in Item 19(b).

Enter the total amount you expect to earn in the current calendar year, in US dollars. Include wages, self-employment income, tips, and other earnings. Provide numbers only; do not include the dollar sign or commas. You may include cents to two decimal places (for example, 25000.00).

Check this box if September is an exempt month, meaning you did not and will not earn more than the specified monthly earnings limit in wages and did not and will not perform substantial services in self-employment during that month.

Check this box if October of this year is an exempt month, meaning you did not or will not earn more than the allowable monthly limit in wages and did not or will not perform substantial self-employment services during that month.

Check this box to show that for November of this year you did not and will not earn more than the stated monthly limit in wages and did not and will not perform substantial self-employment, making it an exempt month.

Check this box if you are completing the earnings-exemption section for the last four months of your taxable year and you did not and will not earn more than the specified monthly limit in wages or perform substantial self-employment in December, making it an exempt month.

Check this box if you did not or will not earn more than the specified monthly earnings limit and did not or will not perform substantial services in self-employment in August, thereby designating it as an exempt month.

Check this box if for July of this year you did not and will not earn more than the applicable monthly earnings limit in wages and did not and will not perform substantial services in self-employment.

Check this box if you did not and will not earn more than the applicable monthly earnings limit and did not perform substantial self‐employment services during June, making it an exempt month.

Enter the four-digit calendar year for which you expect your total earnings under the 'Work Changes' section. Required when reporting a change in expected earnings. Use format YYYY (for example, 2023).

Enter the total earnings you expected for the year entered in the “Year” field. Provide the amount in US dollars using numbers only; do not include the dollar sign ($), commas, or cents.

Check this box if you are earning wages that exceed the monthly amount you entered on your application.

Check this box if you are not earning wages that exceed the monthly amount you reported.

Check this box if you are not self-employed rendering substantial services in your trade or business when reporting your work changes for Social Security retirement benefits.

Check this box if you are self-employed and render substantial services in your trade or business.

Enter the monthly earnings limit in whole dollars, omitting any cents, commas, or currency symbols. For example, enter 1850 to indicate $1,850.

Complete only if you answered “No” to 16(a) Did you have wages or self-employment income covered under Social Security in all years from 1978 through last year? List the years from 1978 through last year in which you did not have any wages or self-employment income covered under Social Security. Enter each year as a four-digit number, separated by commas; use a hyphen to denote consecutive ranges (e.g., 1980, 1984-1986). If there are no such years, enter "NONE".

Enter the full legal name and complete mailing address (street address, city, state, and ZIP code) of your most recent employer. If you had no employment this year, last year, or the year before last, enter “NONE.”

Enter the full name and complete address (street address, city, state abbreviation, and five-digit ZIP code) of the second person, company, or government agency for whom you worked this year, last year, or the year before last. Complete only if you have a second employer; otherwise leave this field blank.

Enter the full legal name and complete mailing address of your third most recent employer, including street address, city, state, and ZIP code. Only complete this field if you have a third employer to report; otherwise leave it blank.

Enter the two-digit month (01–12) when work began for the first employer listed under "NAME AND ADDRESS OF EMPLOYER" in Item 17. Leave this field blank if you entered "NONE" in "NAME AND ADDRESS OF EMPLOYER".

Enter the month as a two-digit number (MM) when you began working for your second most recent employer listed under Name and Address of Employer (e.g., 01 for January). Complete this field only if you have provided a second employer; otherwise leave it blank.

Enter the month (two-digit numeric, MM) when you began work for the third employer listed under Item 17. Complete this only if you are reporting a third employer; otherwise leave blank.

Enter the four-digit year (YYYY) you began work for the first employer listed in Item 17 (your most recent employer). Only required if you list an employer under Item 17.

Enter the four-digit calendar year (YYYY) in the "Work Began" Year column for the second employer listed under "NAME AND ADDRESS OF EMPLOYER" in Item 17. Complete this field if you have entered a second employer.

Enter the four-digit year (YYYY) you began work for the third employer listed under “NAME AND ADDRESS OF EMPLOYER” in Item 17. Complete only if you have entered a third employer; otherwise leave this field blank.

Enter the calendar year (YYYY) you ended employment with the first employer listed under Name and Address of Employer in Item 17. If you are still working for that employer, enter “Not Ended.”

Enter the two-digit number (01–12) for the month your employment ended with the second employer you listed under Item 17 — NAME AND ADDRESS OF EMPLOYER. If you are still working for that employer, enter “Not Ended.” Only complete this field if you listed a second employer in Item 17.

Enter the month you ended work with the third employer listed under “Name and Address of Employer” in Item 17. Use a two-digit month (MM) format (for example, 01 for January). If you are still working for that employer, enter “Not Ended.” If you did not list a third employer, leave this field blank.

Enter the four-digit year (YYYY) in which your employment ended for the first employer listed under Name and Address of Employer. If you are still working for this employer, enter “Not Ended.”

Check this box if May is an exempt month because you did not or will not earn more than the applicable monthly earnings limit and did not or will not perform substantial services in self-employment during that month.

Check this box to show that January is an exempt month in which you did not and will not earn more than the designated wage limit or perform substantial self-employment services.

Check this box if you did not and will not earn more than the applicable monthly earnings limit and did not and will not perform substantial self-employment services in February, making that month exempt.

Check this box if in March you did not and will not earn more than the applicable monthly earnings limit and did not and will not perform substantial self-employment, making March an exempt month.

Check this box if you did not and will not earn more than the allowable monthly earnings nor perform substantial self-employment services during April, making April an exempt month.

Check this box if you will have no exempt months this year—months in which you did not or will not earn more than the exempt earnings limit and did not or will not perform substantial services in self-employment.

Check this box if every month of the year is or will be an exempt month because you did not and will not earn more than the specified amount in wages or perform substantial self-employment.

Check this box if you expect all months of next year to be exempt because you will not earn more than the specified monthly limit or perform substantial self-employment in any month.

Check this box when you do not expect any months next year to be exempt (i.e., months in which you earn no more than the specified limit and perform no substantial self-employment).

Check this box if in April of next year you expect your earnings to be at or below the applicable monthly limit and will not perform substantial self-employment, thus treating April as an exempt month for your retirement insurance benefit calculation.

Check this box if you do not expect to earn more than the indicated monthly earnings limit in wages and will not perform substantial self-employment during August of next year.

Check this box if you expect to earn no more than the specified monthly limit and not perform substantial self-employment in December of next year.

Enter the total amount, in U.S. dollars, you expect to earn next year. Required only if you are now in the last four months of your taxable year. Enter whole-dollar amounts using digits only; omit the dollar sign and commas.

Complete this field only if you use a fiscal year (a taxable year that does not end December 31). Enter the month your fiscal year ends using its full name (for example, June).

Enter your full legal name exactly as shown on your Social Security card: first name, middle initial (omit if none), and last name. Print clearly in capital letters. Required field.

Enter the date the marriage described in Item 14(c) ended. Use month, day, and four-digit year format (MM/DD/YYYY). Required when completing Item 14(c).

Enter the month, day, and four-digit year you were married to the person listed in “To whom married” for your first marriage under item 14(c). Provide this date only if you meet one of the item 14(c) criteria; otherwise leave this field blank. Use the format MM-DD-YYYY (for example, 06-15-2010).

This button provides a link to the Social Security Administration's website.

Check this box if you have never been assigned or used any Social Security number besides the one you provided.

Check this box to indicate you wish to be contacted by telephone regarding your retirement insurance benefits application.

Displays the Office of Management and Budget (OMB) control number associated with this form. This field is automatically populated and should not be edited or filled in by the user.

If you have any change(s) to report that are not listed under the section “CHANGES TO BE REPORTED AND HOW TO REPORT,” enter each change here. For each change, include what happened, the date it occurred, and any relevant details. This field is optional; leave it blank if you have no additional changes to report.

Check this box when you or your spouse have earned Social Security credits under another country’s Social Security program.

Check this box if neither you nor your spouse have Social Security credits under another country’s Social Security system.

Check this box if neither you nor your spouse is applying for foreign Social Security benefits under another country’s system.

Check this box if you or your spouse are filing for foreign Social Security benefits under another country’s Social Security system.

Check this box if you have never been married.

Enter the full name of the language you prefer to speak when communicating with the Social Security Administration (for example, Spanish, Mandarin). Complete this field only if English is not your language preference; otherwise leave it blank and go to item 4.

Complete only if English is not your language preference. Enter the full name of the language in which you prefer to write (for example, Spanish).

Enter the date your self-employment work pattern changes so you can report it to SSA immediately. Complete this field only if your self-employment status or work pattern changes. Enter the date in MM-DD-YYYY format.

This button links to the Social Security Administration's privacy policy webpage.

This button links to the main Social Security Administration website.

This button provides a link to the Social Security Administration's website. Click it to visit the site for more information.

This button provides a link to the Social Security Administration's website. Click it to visit the site for more information.

This button provides a link to the Social Security Administration's website. Click it to visit the site for more information.

Enter the name of the city and state where you married the person listed in “To whom married” under Section 14(c). Use the format “City, State” (for example, “Columbus, OH”). Complete this field only if you are reporting a qualifying marriage under Section 14(c); otherwise enter “None.”

Enter the name of the city and state where the marriage ended. Format as City, State (for example, Chicago, IL). Required when completing the “How marriage ended” field under section 14(c); if no such marriage, enter “None.”

Check this box if you have ever been married.

Enter the full legal name of your current spouse, including maiden name (first name, middle name or initial, and last name). If you are not currently married, enter “None.”

Enter the month, day, and year your current marriage ended. Only complete this field if you entered a termination (for example, divorce, annulment, or death) in How marriage ended (If still in effect, write “Not Ended.”). Leave this field blank if you wrote “Not Ended.” Enter in Month, day, year format (for example, August 5, 2010).

Enter the name of the city and state where your marriage ended. If your marriage is still in effect, write “Not Ended.” Format as City, State (for example, Springfield, IL).

Enter the name of the city and state where your current marriage took place, using the format “City, State” (for example, Seattle, WA). If you are not currently married, enter “None.”

Enter the status or reason your current marriage ended. For example, “Divorced,” “Annulled,” or “Widowed.” If your current marriage is still in effect, enter “Not Ended.”

Enter the name of the city and state where this other marriage occurred. Required if you meet the criteria in Section 14(b): Enter information about any other marriage; otherwise write "None." Format as "City, ST" (for example, "Seattle, WA").

Enter the city and state where your second additional marriage ended as reported in Section 14(b). Complete this field only if you are reporting another marriage under Section 14(b). Use the format “City, ST,” with the two-letter postal abbreviation for the state (for example, “Denver, CO”).

Enter how your second marriage ended. For example, type “Divorced,” “Annulled,” or “Spouse Deceased.” If the marriage is still in effect, enter “Not Ended.” Complete this field only when providing additional marriage information under item 14(b).

Enter the full name (first, middle, last; include maiden name if applicable) of the person to whom you were married in the marriage described in Section 14(c). If you have no such marriage, write “None.”

Enter the way the marriage described in item 14(c) ended using full words— for example, “Divorced,” “Annulled,” or “Death.” If no marriage meets the criteria in item 14(c), enter “None.” Use full words; do not abbreviate.

Check this box if your marriage ceremony was performed by a clergyman or other public official.

Check this box when the marriage was performed by someone other than a clergyman or public official, and provide details in the Remarks section.

Check this box if your marriage was performed by someone other than a clergyman or public official, and provide details in the Remarks section.

Check this box when the marriage you are reporting was officiated by a clergyman or other public official.

Check this box when the applicant’s marriage was performed by someone other than a clergyman or public official, with details provided in the Remarks section.

Check this box if your marriage was officiated by a clergyman or other public official.

Enter the date of death of the spouse named under “To whom married” in section 14(c). Use month, day, and year (MM/DD/YYYY). Complete this field only if that spouse is deceased; otherwise leave it blank.

Use this “Remarks” field to enter additional marriage details as described under 14(b). For each qualifying marriage, provide the spouse’s name (including maiden name), when (Month, day, year), where (Name of City and State), and how the marriage ended. If you have no other qualifying marriage, enter "None". Format dates as Month, day, year.

For the second marriage entry in 14(b) Enter information about any other marriage, enter your spouse’s 9-digit Social Security number. If the spouse never had an SSN or you do not know it, write "None" or "Unknown". Enter digits only (no dashes).

Check this box if you do not want to enroll in Medicare Part B (Medical insurance).

Check this box if you want to enroll in Medicare Part B medical insurance.

Place an uppercase “X” in this box to request enrollment in Medicare Part B (Medical Insurance). Only complete this field if you are within 3 months of age 65 or older (see “COMPLETE ITEM 24 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER”).

This button provides a link to the Medicare website (www.medicare.gov) for more information.

Place an “X” in this box if you expect November of next year to be an exempt month, meaning you will not earn more than the allowable monthly limit in wages and will not perform substantial self-employment during that month.

Check this box if you expect July of next year to be an exempt month by not earning more than the monthly earnings limit and not performing substantial self-employment services during that month.

Check this box if you do not expect to earn more than the indicated monthly limit and will not perform substantial self-employment services in March of the upcoming year, making that month exempt.

Check this box if you do not expect to earn more than the specified monthly wage limit and will not perform substantial self-employment services in February of next year, making it an exempt month.

Check this box if you expect June of next year to be an exempt month because you will not earn more than the allowable monthly limit or perform substantial self-employment during that month.

Check this box if you expect October of next year to be an exempt month by earning no more than the specified monthly limit and performing no substantial self-employment services.

Check this box to indicate that in September of next year you do not expect to earn more than the monthly earnings limit and will not perform substantial self-employment, making that month exempt.

Check this box if during June of next year you do not expect to earn more than the allowable monthly limit and will not perform substantial self-employment services, making June an exempt month.

Check this box if you do not expect to earn more than the allowable monthly earnings or perform substantial self-employment in January of next year, making January an exempt month.

Check this box if you are not entitled to, and do not expect to be entitled to, a pension or annuity (or lump-sum payment) based on your work after 1956 not covered by Social Security.

Check this box if you are or expect to be entitled to a pension, annuity, or lump-sum payment based on work done after 1956 that was not covered by Social Security.

Check this box to confirm that you agree to promptly notify the Social Security Administration if you become entitled to a pension, annuity, or lump-sum payment based on employment not covered by Social Security or if such pension or annuity stops.

If a person for whom you filed or who is in your care has died, left your care or custody, or changed address, enter that person’s full name, the date of the change (MM/DD/YYYY), and a brief description of the event. Complete this field only if such a custody change occurred since you filed your claim; otherwise leave it blank.

Enter your nine-digit Social Security number in the format XXX-XX-XXXX (for example, 123-45-6789). This field is required.

Print your full legal name as it appears on your Social Security record: enter your first name, middle initial (without a period), and last name. Write in uppercase letters, using only letters (and hyphens or apostrophes if part of your legal name).

Enter your date of birth as month, day, and year using two digits for the month and day and four digits for the year (MM DD YYYY).

Enter the city and state, or foreign country, where you were born. For a U.S. birth, type the city name, then a comma and space, then the full state name (for example, “Seattle, Washington”). For a non-U.S. birth, type only the country name (for example, “Canada”).

If you answered “Yes” to “Have you used any other name(s)?” in item 7(a), enter every other name you have used (for example, maiden name, previous married names, legal aliases). Provide each name as First name, Middle initial, Last name. Separate multiple names with commas or place each on its own line. Leave blank if you answered “No” to item 7(a).

If you answered Yes to (a) Have you used any other Social Security number(s)?, enter each Social Security number you have used in the past. Provide the full nine-digit number for each, without spaces or hyphens (for example, 123456789). If you have more than one number, separate them with commas.

Check this box if you have ever used any name other than the one you provided on this retirement insurance benefits application.

Check this box if you have used any Social Security number(s) other than the one currently assigned to you.

Check this box if you have never used any name other than the one you provided as your current legal name.

If your name at birth differs from the name you entered in PRINT your name, enter your first name, middle initial, and last name exactly as shown on your birth record. Leave this field blank if it is the same.

Enter the word NONE (in all capital letters) only if you have no unmarried children under age 18, no children age 18–19 attending full-time secondary or elementary school, and no disabled or handicapped children (disability began before age 22) or students age 18–23 meeting those conditions. Leave this field blank if you are listing any eligible children below.

Enter the full name of the county in which you currently live (for example, “Orange County”). Complete only if you reside in a county; if not, leave this field blank. Use the county’s official name without abbreviations.

Sign in ink using your legal name: enter your First Name, Middle Initial, and Last Name exactly as you want your official signature to appear. This field is required.

Enter the telephone number(s) at which the Social Security Administration may contact you during the day. Provide each number with area code in the format NPA-NXX-XXXX (for example, 555-123-4567). If you wish to list more than one number, separate each with a comma. This field is required.

Enter the date you sign this application in Month, day, year format (e.g., 04/15/2023). This field is required as part of the Signature of Applicant section.

Enter the claim number assigned by the Social Security Administration to your retirement insurance benefits application. If you have received your claim number, type the exact sequence of digits (and any letters) as shown—do not add spaces or hyphens. Leave this field blank if no claim number has been issued yet.

Enter your preferred method for reporting changes to the Social Security Administration. Type exactly one of these options: online, telephone, mail, or in person.

If you check “(c) I want benefits beginning with,” enter the month and year you want your benefits to begin in the format “Month YYYY” (for example, June 2024). Leave this blank unless you select “(c) I want benefits beginning with.”

Check this box if you were self-employed during the current year.

Check this box if you were self-employed during last year.

Enter the date of birth of your second spouse in Month, day, year format (MM-DD-YYYY). If you do not know the exact birth date, enter the spouse’s age in whole years. Only complete this field when filling out (b) Enter information about any other marriage on Form SSA-1-BK.

Only complete this field when reporting current marriage information in item 14(a). Enter your current spouse’s 9-digit Social Security number as a continuous string (no hyphens or spaces). If your spouse does not have a number or you do not know it, enter “None” or “Unknown.”

Enter your spouse’s date of birth in Month, day, year format (for example, June 15, 1960). If the exact date is unknown, enter your spouse’s current age in years. Complete this field only if you have entered a spouse’s name under “Spouse’s name (including maiden name)”.

Enter the full name of your other spouse, including maiden name. Complete this field only if you had an additional marriage as described in section 14(b); if you had no such marriage, enter “None.”

Complete this field only if you provided details about another marriage in Section 14(b). Enter the nine-digit Social Security number of that spouse. If they have no SSN or you do not know it, type “None” or “Unknown.” Include all nine digits; you may use hyphens (for example, 123-45-6789).

Enter the third spouse’s nine-digit Social Security number for the marriage reported in item 14(c) in the ###-##-#### format. Only complete if you provided a spouse in item 14(c); if none or unknown, enter “None” or “Unknown.”

Enter the spouse’s date of birth in Month, day, year format (e.g., January 1, 1970) or, if unknown, enter the spouse’s age in whole years for the third marriage reported in the “To whom married” field of section 14(c). If “None” is entered in “To whom married,” leave this field blank.

If your spouse is deceased, enter the date of death in Month, day, year format (for example, June 15, 2020). Leave this field blank if your spouse is still living.

Enter the date of death of your second spouse using month, day, and four-digit year in MM-DD-YYYY format. Only complete this field if your second spouse is deceased; otherwise, leave it blank.

Check this box if you have already completed the Application for Wife’s or Husband’s Insurance Benefits and only need to fill out the circled items on this form.

Check this box if you are within two months of age 65 or older, or are blind or disabled, and you do not want to file for Supplemental Security Income in connection with your retirement insurance benefits application.

Check this box if the applicant is within two months of turning 65 (or is blind or disabled) and elects to file for Supplemental Security Income.

Sign your full legal name (First Name, Middle Initial, Last Name) in ink as the first witness. This field is required only if the applicant signed by mark (X) in the 'SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)' field.

Enter the handwritten signature (in ink) of the second witness. Only complete this field if “Signature of Applicant” was signed by mark (X).