Form SSA-10, Application for Widow's or Widower's Insurance Benefits Completed Form Examples and Samples
Explore a detailed example of a completed Form SSA-10, Application for Widow's or Widower's Insurance Benefits. Learn step-by-step how to accurately fill out the form with this comprehensive guide. Ideal for widows seeking insurance benefits, it includes crucial details such as personal and deceased spouse's information, certification, and signature instructions.
SSA-10 Example – Application for Widow's Insurance Benefits
How this form was filled:
This example demonstrates how to fill out Form SSA-10 for a widow applying for insurance benefits. The form includes personal information, the deceased spouse's details, and the applicant's declaration and signature.
Information used to fill out the document:
- Applicant's Name: Mary Smith
- Applicant's Social Security Number: 123-45-6789
- Deceased Spouse's Name: John Smith
- Deceased Spouse's Social Security Number: 987-65-4321
- Date of Birth: 1950-05-15
- Date of Marriage: 1975-06-20
- Date of Spouse's Death: 2023-04-25
- Certification: Mary Smith
- Date Signed: 2025-03-15
What this filled form sample shows:
- Accurate applicant and spouse information including Social Security Numbers
- Properly completed date fields reflecting marriage and death
- Included certification and signature
- Demonstrates form customization for 2025 application
Form specifications and details:
| Use Case: | Application for Widow's Insurance Benefits |
| Form Type: | SSA-10 |
| Year: | 2025 |
