Form SSA-10, Widow's or Widower's Benefits Instructions
This form contains 13 fields organized into 1 section. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Form SSA-10-I N S T (07-2020) U F Discontinue Prior Editions Social Security Administration CHANGES TO BE REPORTED AND HOW TO REPORT FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES O M B Number 0960-0004 Page 1 of 2 REPORTING RESPONSIBILITIES FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS • You change your mailing address for checks or residence. (To avoid delay in receipt of checks, you should ALSO file a regular change of address notice with your post office.) • Your citizenship or immigration status changes. • You go outside the U.S.A. for 30 consecutive days or longer. • Any beneficiary dies or becomes unable to handle benefits. • Work Changes - On your application you told us you expect total earnings for blank to be $ blank a month. Total earnings for | Text | |
| amount a month | Text | |
| You (are) earning wages of more than $ blank a month | CheckBox | |
| You (are not) earning wages of more than $ blank a month | CheckBox | |
| amount a month | Text | |
| You (are) self- employed rendering substantial services in your trade or business | CheckBox | |
| You (are not) self- employed rendering substantial services in your trade or business | CheckBox | |
| NOTICE ABOUT DOCUMENTS We recommend that you keep copies of all documents you submitted to us. We are returning the documents you submitted with this claim. (OVER) | CheckBox | |
| (Report AT ONCE if this work pattern changes) • 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. • 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. • 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 flight-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) | Text | |
| WORK AND EARNINGS 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 self- employment 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 | Text | |
| HOW TO REPORT You can make your reports by telephone, mail, in person, or online, whichever you prefer. If you are awarded benefits, and one or more of the above change(s) occur, you should report by: • Visiting the section "Online Services" at our website at www.socialsecurity.gov • 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 • 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 | Text | |
| Page 2 of 2 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 (S O R N) 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 S O R N s, is available on our website at www.ssa.gov/privacy | Text | |
| 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. The O M B 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. You are at the end of the form. If you tab again you will be at the beginning of the form | Text |