This form contains 217 fields organized into 46 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Information
Page 6 of 8 REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)	Text	Use this space to provide any additional explanations or remarks. Attach a separate sheet if more space is needed.
Applicant Declaration
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. SIGNATURE OF APPLICANT Signature (First name, middle initial, last name) (Write in ink) This field requires a wet signature. Fill out form, print then sign in ink	Text	Provide your signature to declare that all information provided is true and correct. This field requires a wet signature, so fill out the form, print it, and sign in ink.
Date (Month, day, year)	Date	Enter the current date in the format Month, Day, Year.
Applicant Information
2.circled (ay) PRINT your name FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter your full name, including first name, middle initial, and last name.
(b) Enter your Social Security Number	Text	Enter your Social Security Number.
(c) Enter your name at birth if different from item 2(a) FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter your name at birth if it is different from the name provided in item 2(a), including first name, middle initial, and last name.
PART II - INFORMATION ABOUT YOURSELF 14. (ay) Enter name of State or foreign country where you were born	Text	Enter the name of the state or foreign country where you were born. This information is used to verify your identity.
Applicant Status
Surviving Spouse	CheckBox	Check this box if you are the surviving spouse of the deceased.
Bank Information
Direct Deposit Payment Address (Financial Institution) Routing Transit Number	Text	Enter the routing transit number of your financial institution for direct deposit payments.
Account Number	Text	Enter your bank account number for direct deposit payments.
Checking	CheckBox	Check this box if the account type for direct deposit is a checking account.
Benefit Start Date
IF YOU ARE FULL RETIREMENT AGE OR OLDER, GO ON TO ITEM 29. OTHERWISE, PLEASE READ CAREFULLY THE INFORMATION ON PAGE 8 AND ANSWER ONE OF THE FOLLOWING ITEMS. 28, circled (ay) After reading the information on page 8, check one of the following: I want benefits beginning with the earliest possible month	CheckBox	Check this box if you want benefits to begin with the earliest possible month after reading the information on page 8.
(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with the earliest possible month,   providing that there is no permanent reduction in my ongoing monthly benefits	CheckBox	Check this box if you are at full retirement age (or will be within 4 months) and want benefits to begin with the earliest possible month without a permanent reduction in ongoing monthly benefits.
(c) I want benefits beginning with blank . I understand that either a higher initial payment or a higher continuing monthly benefit amount may be possible, but I choose not to take it	CheckBox	Check this box if you want benefits to begin with a specific month, understanding that a higher initial payment or ongoing benefit may be possible.
(c) I want benefits beginning with	Date	Enter the specific month you want your benefits to begin.
Birth Record Verification
If you have already presented, or if you are now presenting, a public or religious record of your birth established before you were age 5, go on to item 15. (b) Was a public record of your birth made before age 5? (If yes, go to item 15) Yes	CheckBox	Indicate if a public record of your birth was made before you were age 5. This helps verify your birth details.
No	CheckBox	Select 'No' if a public record of your birth was not made before age 5.
Unknown	CheckBox	Select 'Unknown' if you are unsure whether a public record of your birth was made before age 5.
(c) Was a religious record of your birth made before age 5	CheckBox	Indicate if a religious record of your birth was made before you were age 5. This helps verify your birth details.
No	CheckBox	Select 'No' if a religious record of your birth was not made before age 5.
Unknown	CheckBox	Select 'Unknown' if you are unsure whether a religious record of your birth was made before age 5.
Claim Information
DATE CLAIM RECEIVED	Date	Enter the date on which your claim for Social Security benefits was received by the SSA.
SOCIAL SECURITY CLAIM NUMBER	Text	Enter the Social Security claim number associated with this application.
Claim Processing Time
Your application for Social Security benefits has been received and will be processed as quickly as possible. You should hear from us within blank days after you have given us all the information we requested. Some claims may take longer if additional information is needed. Enter amount of days	Text	Specify the number of days within which you expect to hear back from the SSA after submitting all requested information for your claim.
Claimant Information
In the meantime, if you change your address, or if there is some other change that may affect your claim, you - or someone for you - should report the change. The changes to be reported are listed on page 8. Always give us your claim number when writing or telephoning about your claim. If you have any questions about your claim, we will be glad to help you. Claimant	Text	Enter the name of the claimant. This is the person who should report any changes in address or other details that may affect the claim.
Contact Information
Telephone number(s) at which you may be contacted during the day	Text	Provide the telephone number(s) where you can be contacted during the day.
Applicant's Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)	Text	Enter your mailing address, including number, street, apartment number, P.O. Box, or rural route. If your residence address is different, enter it in the 'Remarks' section.
City and State	Text	Enter the city and state of your mailing address.
ZIP Code	Text	Enter the ZIP Code of your mailing address.
Country (if any) in which you now live	Text	Enter the country where you currently reside, if applicable.
Page 7 of 8 RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY WIDOW'S OR WIDOWER'S INSURANCE BENEFITS TELEPHONE NUMBER(S) TO CALL IF YOU HAVE A QUESTION OR SOMETHING TO REPORT BEFORE YOU RECEIVE A NOTICE OF AWARD	Text	Provide the telephone number(s) you can be reached at if there are questions or updates needed before you receive a notice of award for your Social Security Widow's or Widower's Insurance Benefits.
AFTER YOU RECEIVE A NOTICE OF AWARD	Text	Provide the telephone number(s) you can be reached at if there are questions or updates needed after you receive a notice of award for your Social Security Widow's or Widower's Insurance Benefits.
Date Selection
November	CheckBox	Check this box if the relevant information or event occurred in November.
ALL	CheckBox	Check this box if the relevant information or event applies to all months.
Deceased Information
Form SSA-10 (10-2019) UF Discontinue Prior Editions SOCIAL SECURITY ADMINISTRATION Form Approved O M B number 0960-0004 APPLICATION FOR WIDOW'S OR WIDOWER'S INSURANCE BENEFITS* Page 1 of 8 (Do not write in this space) With this application, you are applying for all insurance benefits for which you are eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act as presently amended. The information you furnish on this application will ordinarily be sufficient for a determination on the lump-sum death payment.?If you were receiving spouse's benefits at the time of your spouse's death, you only need to complete the circled items. All other claimants must complete the entire form.?*This may also be considered an application for survivors benefits under the Railroad Retirement Act and for Veterans Administration payments under title 38 U.S.C., Veterans Benefits, Chapter 13 (which is, as such, an application for other types of death benefits under title 38). 1. circled (ay) PRINT name of deceased wage earner or self-employed person (herein referred to as the "deceased") FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter the full name of the deceased wage earner or self-employed person, including first name, middle initial, and last name.
(b) circled Check (X) one for the deceased male	CheckBox	Check this box if the deceased was male.
Female	CheckBox	Check this box if the deceased was female.
(c) Enter deceased's Social Security Number	Text	Enter the Social Security Number of the deceased.
PART I - INFORMATION ABOUT THE DECEASED 3. Enter date of birth of deceased MONTH, DAY, YEAR	Date	Enter the date of birth of the deceased, including month, day, and year.
4. circled (ay) Enter date of death MONTH, DAY, YEAR	Date	Enter the date of death of the deceased, including month, day, and year.
(b) Enter place of death city and state	Text	Enter the city and state where the deceased passed away.
5 circled Enter name of the State or foreign country where the deceased had a fixed, permanent home at the time of death	Text	Enter the name of the state or foreign country where the deceased had a fixed, permanent home at the time of death.
DECEASED'S SURNAME IF DIFFERENT FROM CLAIMANT'S	Text	If the deceased's surname is different from the claimant's, enter the deceased's surname here.
Deceased's Earnings
Page 2 of 8 ANSWER ITEM 9 ONLY IF DEATH OCCURRED WITHIN THE LAST 2 YEARS. 9. (ay) About how much did the deceased earn from employment and self-employment during the year of death? Amount	Number	Enter the approximate amount the deceased earned from employment and self-employment during the year of their death. This is only required if the death occurred within the last 2 years.
(b) About how much did the deceased earn the year before death? Amount	Number	Enter the approximate amount the deceased earned from employment and self-employment in the year before their death.
Deceased's Marriage History
INFORMATION ABOUT THE DECEASED'S MARRIAGE(S) 12. Answer this item ONLY if the deceased had other marriages. (ay) If the deceased married after his or her marriage to you, enter the information on the last marriage. (If none, write "NONE".) Spouse's Name (including maiden name)	Text	Provide the name of the deceased's last spouse, including maiden name, if the deceased married after their marriage to you. If there were no other marriages, write 'NONE'.
When (Month, Day, and Year)	Date	Enter the date (Month, Day, and Year) of the deceased's last marriage.
Where (Name of City and State)	Text	Enter the city and state where the deceased's last marriage took place.
Where (Name of City and State)	Text	Enter the city and state where the deceased's last marriage took place.
(b) If the deceased had any other marriages, and the marriage lasted at least 10 years or ended due to death of the spouse (whether before or after you married the deceased), enter the information below. If the deceased divorced then remarried the same individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more, include the marriage. (If none, write "NONE".) Spouse's Name (including maiden name)	Text	If the deceased had any other marriages that lasted at least 10 years or ended due to the death of the spouse, provide the name of the spouse, including maiden name. If none, write 'NONE'.
Deceased's Military Service
No (If "No," go on to item 9.)	CheckBox	Check this box if the deceased was not in active military or naval service after September 7, 1939, and before 1968.
8. (ay) Was the deceased in the active military or naval service (including Reserve or National Guard active duty or active duty for training) after September 7, 1939 and before 1968? Yes (If "Yes," answer (b) and (c).)	CheckBox	Check this box if the deceased was in active military or naval service (including Reserve or National Guard active duty or active duty for training) after September 7, 1939, and before 1968.
(b) Enter dates of service. (Month, year) FROM	Date	Enter the start date (month, year) of the deceased's military service.
(Month, year) TO	Date	Enter the end date (month, year) of the deceased's military service.
Deceased's Social Security Applications
No (If "No, "go on to item 7.)	CheckBox	Check this box if the deceased did not file an application for Social Security benefits, a period of disability, supplemental security income, or Medicare insurance.
6. (a) Did the deceased ever file an application for Social Security benefits, a period of disability under Social Security, supplemental security income, or hospital or medical insurance under Medicare? Yes (If "Yes," answer (b) and (c).)	CheckBox	Check this box if the deceased filed an application for Social Security benefits, a period of disability, supplemental security income, or Medicare insurance.
If unknown, check this box	CheckBox	Check this box if it is unknown whether the deceased filed an application for Social Security benefits, a period of disability, supplemental security income, or Medicare insurance.
(b) Enter name(s) of person(s) on whose Social Security record(s) other application was filed. FIRST NAME, MIDDLE INITIAL, LAST NAME	Text	Enter the full name (first name, middle initial, last name) of the person(s) on whose Social Security record(s) another application was filed.
(c) Enter Social Security Number(s) of person(s) named in (b)	Text	Enter the Social Security Number(s) of the person(s) named in the previous field.
If unknown, check this box	CheckBox	Check this box if the Social Security Number(s) of the person(s) named in the previous field is unknown.
Deceased's Work Ability
No (If "No," go on to item 8.)	CheckBox	Check this box if the deceased was not unable to work due to illnesses, injuries, or conditions at the time of death.
Answer Item 7 Only if the Deceased Died Prior to Full Retirement Age or Prior to 1 Year Past Full Retirement Age, and Within the Past 4 Months. 7 Circled (ay) Was the deceased unable to work because of illnesses, injuries or conditions at the time of death? Yes (If "Yes," answer (b).)	CheckBox	Check this box if the deceased was unable to work due to illnesses, injuries, or conditions at the time of death.
(b) Enter the date the deceased became unable to work. MONTH,DAY,YEAR	Date	Enter the date (month, day, year) when the deceased became unable to work.
Disability Information
(b) Enter the date you became unable to work. (Month, day, year)	Date	Enter the date you became unable to work, including month, day, and year.
Earnings and Employment
(b) Place an "X" in each block for each month of this year in which you did not or will not earn more than $ blank in wages, and did not or will not perform substantial services in self-employment. These months are exempt months. If no months are or will be exempt months, place an "X" in "NONE." If all months are or will be exempt months, place an "X" in "ALL." Enter the appropriate monthly limit after reading the information, "How Work Affects Your Benefits." Enter wages	Number	Enter the monthly wage limit after reading the section 'How Work Affects Your Benefits'. Indicate the months in which you did not or will not earn more than this limit and did not perform substantial services in self-employment by placing an 'X' in the corresponding boxes. If no months are exempt, mark 'NONE'. If all months are exempt, mark 'ALL'.
January	CheckBox	Check this box if January is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
February	CheckBox	Check this box if February is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
April	CheckBox	Check this box if April is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
March	CheckBox	Check this box if March is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
NONE	CheckBox	Check this box if none of the months are exempt months where you did not earn more than the specified limit and did not perform substantial services in self-employment.
May	CheckBox	Check this box if May is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
June	CheckBox	Check this box if June is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
August	CheckBox	Check this box if August is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
July	CheckBox	Check this box if July is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
September	CheckBox	Check this box if September is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
October	CheckBox	Check this box if October is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
December	CheckBox	Check this box if December is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
November	CheckBox	Check this box if November is an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
ALL	CheckBox	Check this box if all months are exempt months where you did not earn more than the specified limit and did not perform substantial services in self-employment.
Earnings and Work Activity
(b) Place an "X" in each block for each month of last year in which you did not earn more than $ blank in wages, and did not perform substantial services in self-employment. These months are exempt months. If no months were exempt months, place an "X" in "NONE." If all months were exempt months, place an "X" in "ALL." Enter the appropriate monthly limit after reading the information, "How Work Affects Your Benefits." Enter the amount of wages	Number	Enter the monthly wage limit after reading 'How Work Affects Your Benefits'. Place an 'X' in each block for each month of last year in which you did not earn more than this amount and did not perform substantial services in self-employment. Mark 'NONE' if no months were exempt, or 'ALL' if all months were exempt.
January	CheckBox	Check this box if January was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
February	CheckBox	Check this box if February was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
April	CheckBox	Check this box if April was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
March	CheckBox	Check this box if March was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
NONE	CheckBox	Check this box if none of the months last year were exempt months.
May	CheckBox	Check this box if May was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
June	CheckBox	Check this box if June was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
August	CheckBox	Check this box if August was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
July	CheckBox	Check this box if July was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
September	CheckBox	Check this box if September was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
October	CheckBox	Check this box if October was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
December	CheckBox	Check this box if December was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
November	CheckBox	Check this box if November was an exempt month where you did not earn more than the specified limit and did not perform substantial services in self-employment.
ALL	CheckBox	Check this box if all months last year were exempt months.
25. circled (ay) How much do you expect your total earnings to be this year	Number	Enter the total amount you expect to earn this year.
Earnings Evidence
11. CHECK IF APPLICABLE I am not submitting evidence of the deceased's earnings that are not yet on his/her earnings record. I understand that these earnings will be included automatically within 24 months, and any increase in my benefits will be paid with full retroactivity	CheckBox	Check this box if you are not submitting evidence of the deceased's earnings that are not yet on their earnings record. These earnings will be included automatically within 24 months, and any increase in benefits will be paid with full retroactivity.
Eligibility Questions
No No(If "No," answer (b).)	CheckBox	Check 'No' if the answer to the previous question is 'No'. If 'No', answer the subsequent question (b).
Employment History
No	CheckBox	Select this checkbox if neither you nor the deceased worked in the railroad industry for 5 years or more.
20. Did you or the deceased work in the railroad industry for 5 years or more? Yes	CheckBox	Select this checkbox if you or the deceased worked in the railroad industry for 5 years or more.
Employment Status
(If "No," go on to item 19.) No	CheckBox	Select this checkbox if you have not been unable to work due to illnesses, injuries, or conditions in the past 14 months.
Page 4 of 8 DO NOT ANSWER QUESTION 18 IF YOU ARE FULL RETIREMENT AGE OR OLDER. GO ON TO QUESTION 19. 18. (ay) Are you, or during the past 14 months have you been, unable to work because of illnesses, injuries or conditions? Yes (If "Yes," answer (b) .)	CheckBox	Select this checkbox if you have been unable to work because of illnesses, injuries, or conditions during the past 14 months.
You are not earning wages of more than blank a month	CheckBox	Check this box if you are not earning more than the specified amount per month. This information is necessary to evaluate your eligibility for benefits.
You (are) self-employed rendering substantial services in your trade or business	CheckBox	Check this box if you are self-employed and providing substantial services in your trade or business. This affects your eligibility and benefit calculations.
You (are not) self-employed rendering substantial services in your trade or business	CheckBox	Check this box if you are not self-employed or not providing substantial services in your trade or business. This information is used to determine your eligibility for benefits.
Exempt Months
January	CheckBox	Check this box if January is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
February	CheckBox	Check this box if February is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
April	CheckBox	Check this box if April is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
March	CheckBox	Check this box if March is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
NONE	CheckBox	Check this box if no months are expected to be exempt months where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
May	CheckBox	Check this box if May is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
June	CheckBox	Check this box if June is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
August	CheckBox	Check this box if August is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
July	CheckBox	Check this box if July is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
September	CheckBox	Check this box if September is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
October	CheckBox	Check this box if October is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
December	CheckBox	Check this box if December is an exempt month where you do not expect to earn more than the specified monthly limit in wages or perform substantial services in self-employment.
Family Support Information
USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER MARRIAGE AS DESCRIBED IN 12b. 13. circled Is there a surviving parent (or parents) who was receiving support from the deceased at the time of death or at the time the deceased became disabled under Social Security Law? (If "yes," enter the name and address in "Remarks.")	CheckBox	Indicate if there is a surviving parent who was receiving support from the deceased at the time of death or disability. If yes, provide their name and address in the 'Remarks' section.
Federal Benefits
No	CheckBox	Select this checkbox if no one, including the deceased, has received or expects to receive a benefit from any other Federal agency.
(c) Has anyone (including the deceased) received, or does anyone expect to receive, a benefit from any other Federal agency? Yes	CheckBox	Select this checkbox if anyone, including the deceased, has received or expects to receive a benefit from any other Federal agency.
Financial Information
I received a lump sum in place of a government pension or annuity	CheckBox	Indicate whether you have received a lump sum payment in place of a government pension or annuity.
I applied for and am awaiting a decision on my pension or lump sum	CheckBox	Check this box if you have applied for a pension or lump sum and are awaiting a decision.
I have not applied for but I expect to begin receiving my pension or annuity	CheckBox	Select this option if you have not applied for a pension or annuity but expect to start receiving it.
Page 5 of 8 ANSWER ITEM 24 ONLY IF THE DECEASED DIED BEFORE THIS YEAR. 24. circled (ay) How much were your total earnings last year	Number	Provide your total earnings from last year if the deceased died before this year.
ANSWER ITEM 26 ONLY IF YOU ARE NOW IN THE LAST 4 MONTHS OF YOUR TAXABLE YEAR (SEPT., OCT., NOV., AND DEC., IF YOUR TAXABLE YEAR IS A CALENDAR YEAR). 26. circled (ay) How much do you expect to earn next year	Number	Enter the amount you expect to earn in the next year if you are currently in the last four months of your taxable year (September, October, November, and December, if your taxable year is a calendar year).
(b) Place an "X" in each block for each month of next year in which you do not expect to earn more than $ blank in wages, and do not expect to perform substantial services in self-employment. These months will be exempt months. If no months are expected to be exempt months, place an "X" in "NONE." If all months are expected to be exempt months, place an "X" in "ALL." Enter the appropriate monthly limit after reading the information, "How Work Affects Your Benefits." Enter wages	Text	Place an 'X' in each block for each month of the next year in which you do not expect to earn more than the specified monthly limit in wages, and do not expect to perform substantial services in self-employment. These months will be considered exempt months. If no months are expected to be exempt, place an 'X' in 'NONE.' If all months are expected to be exempt, place an 'X' in 'ALL.'
27. Circled If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15), enter here the month your fiscal year ends. Month	Text	Enter the month in which your fiscal year ends if it does not end on December 31.
Savings	CheckBox	Indicate if you have a savings account by checking this box.
Enroll in Direct Express	CheckBox	Check this box if you wish to enroll in the Direct Express program for receiving benefits.
Direct Deposit Refused	CheckBox	Check this box if you refuse to use direct deposit for receiving benefits.
amount a month	Number	Enter the amount of money you receive per month. This could include wages, benefits, or any other regular income.
You are earning wages of more than blank a month	CheckBox	Check this box if you are earning wages of more than a specified amount per month. This information is used to determine your eligibility for benefits.
Page 8 of 8 CHANGES TO BE REPORTED AND HOW TO REPORT FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID, AND IN POSSIBLE MONETARY PENALTIES. • 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. Enter total earnings for	Number	Enter the total earnings you expect for the specified period. This information is used to assess your eligibility for benefits and ensure accurate payment amounts.
Work Changes - On your application you told us you expect total earnings for blank to be $ blank. Enter amount to be	Number	Provide the amount you expect to earn for the specified period. This helps determine your eligibility and the correct amount of benefits.
General Information
(Month, day, year) (If the date is not known, enter "Unknown".)	Date	Enter the date in the format Month, Day, Year. If the date is unknown, enter 'Unknown'.
No	CheckBox	Select 'No' if the statement or question does not apply to you.
Government Pension
No (If "no," go on to item 23.)	CheckBox	Select this checkbox if you do not qualify for, nor expect to qualify for, a pension or annuity based on your own employment and earnings for the Federal Government or its subdivisions.
22. (ay) Have you qualified for, or do you expect to qualify for, a pension or annuity (or a lump sum in place of a pension or annuity) based on your own employment and earnings for the Federal Government of the United States, or one of its States or local subdivisions that was not covered under Social Security? (Social Security benefits are not government pensions.) Yes (If "Yes," check which of the items in item (b) applies to you.)	CheckBox	Select this checkbox if you qualify for, or expect to qualify for, a pension or annuity based on your own employment and earnings for the Federal Government or its subdivisions.
(b) I receive a government pension or annuity	CheckBox	Select this checkbox if you receive a government pension or annuity.
International Social Security
No (If "No,"go on to item 22.)	CheckBox	Select this checkbox if neither you nor the deceased have Social Security credits under another country's Social Security System.
21. (ay) Did you or the deceased have Social Security credits (for example, based on work or residence) under another country's Social Security System? Yes (if "yes," answer (b),)	CheckBox	Select this checkbox if you or the deceased have Social Security credits under another country's Social Security System.
(b) If "Yes," list the country(ies)	Text	List the countries where you or the deceased have Social Security credits if applicable.
Living Situation
USE "REMARKS" SPACE ON BACK PAGE FOR INFORMATION ABOUT ANY OTHER MARRIAGE AS DESCRIBED IN 15c. IF YOU ARE APPLYING FOR SURVIVING DIVORCED SPOUSE'S BENEFITS, OMIT 16 AND GO ON TO ITEM 17. 16. circled (ay) Were you and the deceased living together at the same address when the deceased died? Yes (If "Yes," go to item 17.)	CheckBox	Indicate whether you and the deceased were living together at the same address when the deceased passed away. If yes, proceed to item 17.
(b) If either you or the deceased were away from home (whether or not temporarily) when the deceased died, give the following: Who was away? Deceased	CheckBox	Specify if the deceased was away from home at the time of death.
Date last at home	Date	Enter the date when the deceased was last at home.
Reason absence began	Text	Provide the reason why the absence from home began.
Reason you were apart at time of death	Text	Explain the reason for being apart from the deceased at the time of their death.
If separated because of illness, enter nature of illness or disabling condition	Text	If the separation was due to illness, describe the nature of the illness or disabling condition.
No(If "No," go to item 18).)	CheckBox	Indicate if you were not living with the deceased at the time of their death. If no, proceed to item 18.
Marriage Details
When (Month, Day, and Year)	Date	Enter the date when the marriage took place, using the format Month, Day, and Year.
How Marriage Ended	Text	Specify how the marriage ended, such as divorce, annulment, or death.
Marriage performed by Clergyman or public official	CheckBox	Check this box if the marriage was performed by a clergyman or public official.
Other (Explain in Remarks)	CheckBox	Check this box if the marriage was performed by someone other than a clergyman or public official, and explain in the remarks section.
When (Month, Day, and Year)	Date	Enter the date when the marriage took place, using the format Month, Day, and Year.
Where (Name of City and State)	Text	Enter the name of the city and state where the marriage took place.
Where (Name of City and State)	Text	Enter the name of the city and state where the marriage took place.
When (Month, Day, and Year)	Date	Enter the date when the marriage took place, using the format Month, Day, and Year.
How Marriage Ended	Text	Specify how the marriage ended, such as divorce, annulment, or death.
Marriage performed by Clergyman or public official	CheckBox	Check this box if the marriage was performed by a clergyman or public official.
Other (Explain in Remarks)	CheckBox	Check this box if the marriage was performed by someone other than a clergyman or public official, and explain in the remarks section.
Where (Name of City and State)	Text	Enter the name of the city and state where the marriage took place.
When (Month, Day, and Year)	Date	Enter the date when the marriage took place, including month, day, and year.
How Marriage Ended	Text	Specify how the marriage ended, such as divorce, annulment, or death.
Marriage performed by Clergyman or public official	CheckBox	Check this box if the marriage was performed by a clergyman or public official.
Other (Explain in Remarks)	CheckBox	Check this box if the marriage was performed by someone other than a clergyman or public official and explain in the remarks section.
(b) If you remarried after the marriage shown in 15.(a). enter information about the last marriage. (If none, write "NONE".) Spouse's Name (including maiden name)	Text	If you remarried after the marriage shown in 15.(a), enter the full name of your last spouse, including maiden name. If you did not remarry, write 'NONE'.
When (Month, Day, and Year)	Date	Enter the date when the last marriage took place, including month, day, and year.
Where (Name of City and State)	Text	Enter the name of the city and state where the last marriage took place.
Where (Name of City and State)	Text	Enter the name of the city and state where the marriage took place.
When (Month, Day, and Year)	Date	Enter the date when the marriage took place, including month, day, and year.
How Marriage Ended	Text	Specify how the marriage ended, such as divorce, annulment, or death.
Marriage performed by Clergyman or public official	CheckBox	Check this box if the marriage was performed by a clergyman or public official.
Other (Explain in Remarks)	CheckBox	Check this box if the marriage was performed by someone other than a clergyman or public official and explain in the remarks section.
Marriage History
(c) Enter information about any other marriage you may have had that lasted at least 10 years (see item 12(b) for counting consecutive multiple marriages to the same individual) or ended due to death of the spouse (whether before or after you married the deceased). (If none, write "NONE".) Spouse's Name (including maiden name)	Text	Provide the name of any other spouse you were married to for at least 10 years or whose marriage ended due to their death. Include maiden name if applicable. If none, write 'NONE'.
When (Month, Day, and Year)	Date	Enter the date (Month, Day, and Year) of the marriage mentioned in the previous field.
Where (Name of City and State)	Text	Enter the city and state where the marriage mentioned in the previous field took place.
Where (Name of City and State)	Text	Enter the city and state where the marriage mentioned in the previous field took place.
When (Month, Day, and Year)	Date	Enter the date (Month, Day, and Year) of the marriage mentioned in the previous field.
How Marriage Ended	Text	Describe how the marriage ended (e.g., divorce, death).
Marriage performed by Clergyman or public official	CheckBox	Check this box if the marriage was performed by a clergyman or public official.
Other (Explain in Remarks)	CheckBox	Check this box if the marriage was performed by someone other than a clergyman or public official and explain in the remarks section.
Marriage Information
Page 3 of 8 INFORMATION ABOUT YOUR MARRIAGE(S) 15. (ay) Enter information about your marriage to the deceased. Spouse's Name (including maiden name)	Text	Enter the full name of your spouse, including their maiden name, for your marriage to the deceased. This is required to verify marriage details.
When (Month, Day, and Year)	Date	Enter the date of your marriage to the deceased, including the month, day, and year. This information is necessary to verify marriage details.
Where (Name of City and State)	Text	Enter the city and state where your marriage to the deceased took place. This information is necessary to verify marriage details.
Medicare Information
MEDICARE INFORMATION If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of Age 65 or older you could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to contact Social Security to request enrollment.COMPLETE ITEM 23 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined when your coverage begins. In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there is any change in the amount of your premium. You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and when you can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan premium, based on information about your income we receive from the Internal Revenue Service. If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.23.Do you want to enroll in the Medicare Part B (Medical Insurance)? Yes	CheckBox	Indicate if you want to enroll in Medicare Part B (Medical Insurance) if you are within 3 months of age 65 or older.
Military Service
No	CheckBox	Select this checkbox if you were not in the active military or naval service after September 7, 1939, and before 1968.
19. Were you in the active military or naval service (including Reserve or National Guard active duty or active duty for training) after September 7, 1939 and before 1968? Yes	CheckBox	Select this checkbox if you were in the active military or naval service, including Reserve or National Guard active duty or active duty for training, after September 7, 1939, and before 1968.
Previous Applications
17. (a) Have you (or has someone on your behalf) ever filed an application for Social Security benefits, a period of disability under Social Security, Supplemental Security Income, or hospital or medical insurance under Medicare? Yes (If "Yes," answer (b) and (c).)	CheckBox	Indicate if you or someone on your behalf has ever filed an application for Social Security benefits or related services. If yes, answer parts (b) and (c).
(b) Enter name of person on whose Social Security record you  filed other application	Text	Enter the name of the person on whose Social Security record another application was filed.
(c) Enter Social Security Number of person named in (b). (if unknown, check this box)	Text	Enter the Social Security Number of the person named in the previous question. If unknown, check the corresponding box.
If unknown, check this box	CheckBox	Check this box if the Social Security Number of the person named in the previous question is unknown.
Privacy Notice
PRIVACY ACT NOTICE 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 (SORN) 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 SORNs, is available on our website at www.ssa.gov/privacy. 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 (OMB) control number. The OMB 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	Text	This section provides a detailed notice about the Privacy Act and how your personal information will be used and shared by the Social Security Administration. It is important to read and understand this information before proceeding with the application.
Reporting Changes
(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. • 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. • Custody Change - Report if a person for whom you are filing, or who is in your care dies, leaves your care or custody, or changes address. • 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). Disability Applicants 1. You return to work (as an employee or self-employed) regardless of amount of earnings. 2. Your condition improves. 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 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. 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 "What You Can Do Online" at our web site 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 shown at the phone number and address on your claim receipt. For general information about Social Security, visit our web site at www.socialsecurity.gov. FIGURING YOUR ANNUAL EARNINGS To figure your total yearly earnings, count all gross wages (before deductions) and net earnings from self-employment which you earn during the entire year. This includes earning both before and after your retirement date, and applies to all earned income whether or not covered by Social Security. In figuring your total yearly earnings, however, DO NOT COUNT ANY AMOUNTS EARNED BEGINNING WITH THE MONTH YOU ATTAIN FULL RETIREMENT AGE. Count only amounts earned before the you attain full retirement age. PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE ANSWERING QUESTION 28. Benefits may be payable for some months prior to the month in which you file this claim (but not for any month before you reach age 60 (unless you are disabled)) if: • YOU WILL EARN OVER THE EXEMPT AMOUNT THIS YEAR. (For the appropriate exempt amount, see "How Work Affects Your Benefits.") (Publication number 05-10069 If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually receive your full benefit amount for one or more months before full retirement age because benefits are withheld due to your earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at full retirement age will be reduced only you receive one or more full benefit payments prior to the month you attain full retirement age. You are at the end of the form. If you tab again and you will be at the beginning of the form	Text	This field is for reporting any changes in your work pattern, marital status, custody, pension, or legal status that may affect your eligibility for benefits. It also includes instructions on how to report these changes to the Social Security Administration.
Retirement Benefits
No	CheckBox	Check this box if you do not wish this application to be considered for retirement benefits on your own earnings record.
ANSWER QUESTION 29 ONLY IF YOU ARE NOW AT LEAST AGE 61 YEARS, 8 MONTHS. 29. Do you wish this application to be considered an application for retirement benefits on your own earnings record	CheckBox	Check this box if you wish this application to be considered for retirement benefits on your own earnings record, applicable only if you are at least 61 years and 8 months old.
Social Security Coverage
No (If "No," answer (b).)	CheckBox	Select this checkbox if the deceased did not have wages or self-employment income covered under Social Security in all years from 1978 through last year.
10. circled (ay) Did the deceased have wages or self-employment income covered under Social Security in all years from 1978 through last year? Yes (If "Yes," skip to item 11.)	CheckBox	Select this checkbox if the deceased had wages or self-employment income covered under Social Security in all years from 1978 through last year. If selected, skip to item 11.
(b) List the years from 1978 through last year in which the deceased did not have wages or self-employment income covered under Social Security	Text	List the years from 1978 through last year in which the deceased did not have wages or self-employment income covered under Social Security.
Spouse Information
Spouse's date of birth (or age)	Text	Provide the date of birth or age of the spouse.
If spouse deceased, give date of death	Date	If the spouse is deceased, enter the date of death.
Spouse's Social Security Number (If none or unknown, so indicate)	Text	Enter the Social Security Number of the spouse. If it is unknown or the spouse does not have one, indicate that.
Spouse's date of birth (or age)	Text	Enter the date of birth or the age of your spouse. This information is required to verify the identity and eligibility of the applicant.
If spouse deceased, give date of death	Date	If your spouse is deceased, provide the date of their death. This is necessary to determine eligibility for survivor benefits.
Spouse's Social Security Number (If none or unknown, so indicate)	Text	Enter your spouse's Social Security Number. If it is not available or unknown, please indicate that. This is used to verify the spouse's identity.
Spouse's date of birth (or age)	Text	Enter the date of birth or age of your spouse.
If spouse deceased, give date of death	Date	If your spouse is deceased, provide the date of their death.
Spouse's Social Security Number (If none or unknown, so indicate)	Text	Enter your spouse's Social Security Number. If it is unknown or they do not have one, indicate that.
Spouse's date of birth (or age)	Text	Enter the date of birth or the current age of your spouse.
If spouse deceased, give date of death	Date	If your spouse is deceased, provide the date of their death.
Spouse's Social Security Number (If none or unknown, so indicate)	Text	Enter your spouse's Social Security Number. If it is not available or unknown, please indicate that.
Spouse's date of birth (or age)	Text	Enter the date of birth or the current age of your spouse.
If spouse deceased, give date of death	Date	If your spouse is deceased, provide the date of their death.
Spouse's Social Security Number (If none or unknown, so indicate)	Text	Enter your spouse's Social Security Number. If it is not available or unknown, please indicate that.
SSA Office Information
SSA OFFICE	Text	Enter the name of the Social Security Administration (SSA) office handling your claim.
Witness Information
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature block. 1. Signature of Witness	Text	If the application is signed by mark (X), a witness must sign here and provide their full address. Also, print the applicant's name in the signature block.
Address (Number and Street, City, State and ZIP Code)	Text	Enter the full address of the first witness, including number, street, city, state, and ZIP Code.
Address (Number and Street, City, State and ZIP Code)	Text	Enter the full address of the second witness, including number, street, city, state, and ZIP Code.
2. Signature of Witness	Text	If the application is signed by mark (X), a second witness must sign here.

Form SSA-10, Application for Widow's or Widower's Insurance Benefits Instructions