Form SSA-2-BK, Application for Spouse's Benefits Instructions

Use this space to provide any additional explanations or information. If more space is needed, attach a separate sheet.

Continue providing any additional explanations or information. If more space is needed, attach a separate sheet.

Enter the applicant’s first name, middle initial, and last name.

Enter the applicant’s nine-digit Social Security Number.

Enter the applicant's mailing address, including number and street, apartment number, P.O. Box, or rural route. If the residence address is different, enter it in the 'Remarks' section.

Enter the city and state of the applicant's mailing address.

Enter the ZIP code of the applicant's mailing address.

Enter the county (if any) where the applicant currently resides.

Check this box if you have already completed an application entitled 'APPLICATION FOR RETIREMENT INSURANCE BENEFITS', in which case you need to complete only the circled items on this form.

Enter the number of days within which you should hear back from the Social Security Administration after submitting all requested information.

Check this box if you want benefits beginning with the earliest possible month and will accept an age-related reduction.

Check this box if you are at full retirement age (or will be within 12 months) and want benefits beginning with the earliest possible month without a permanent reduction in ongoing monthly benefits.

Check this box if you want benefits beginning with a specific month. You will need to specify the month.

Enter the date you want your benefits to begin.

Enter the first name of the child who lived with you. This is part of a table where you list the names of children and the months they lived with you.

Enter the months the first child lived with you. If the child lived with you for all months, write 'All'.

Enter the second name of the child who lived with you. This is part of a table where you list the names of children and the months they lived with you.

Enter the months the second child lived with you. If the child lived with you for all months, write 'All'.

Enter the third name of the child who lived with you. This is part of a table where you list the names of children and the months they lived with you.

Enter the months the third child lived with you. If the child lived with you for all months, write 'All'.

Check this box if you are an alien lawfully present in the U.S. Fill only if the 'Are you a U.S. citizen?' is 'No'.

Check this box if you are not an alien lawfully present in the U.S. Fill only if the 'Are you a U.S. citizen?' is 'No'.

Enter the date (month, day, year) you were lawfully admitted to the United States. Fill only if the 'Are you an alien lawfully present in U.S.?' is 'Yes'.

Check this box if you are a U.S. citizen.

Check this box if you are not a U.S. citizen.

Enter the date the claim was received.

Provide the telephone number(s) where you can be contacted during the day.

Enter the telephone number(s) to call if you have a question or something to report before you receive a notice of award.

Enter the telephone number(s) to call if you have a question or something to report after you receive a notice of award.

Enter the SSA office contact information.

Sign and date this declaration to confirm that all the information provided in this form and any accompanying statements or forms is true and correct to the best of your knowledge.

Provide your signature (First Name, Middle Initial, Last Name) in ink. A wet signature is required, so print out the form and sign it.

Check this box if an unmarried child of the worker (including adopted child, stepchild, or dependent grandchild) who is under 16 or disabled has lived with you during any of the last 13 months (including the present month).

Check this box if no unmarried child of the worker (including adopted child, stepchild, or dependent grandchild) who is under 16 or disabled has lived with you during any of the last 13 months (including the present month).

Provide the Routing Transit Number of your financial institution for direct deposit payment.

Provide your account number for direct deposit payment.

Indicate if the account for direct deposit is a checking account.

Indicate if the account for direct deposit is a savings account.

Indicate if you want to enroll in Direct Express for direct deposit.

Indicate if you refuse direct deposit.

Enter the total amount of your earnings from last year.

Place an 'X' in each block for each month of last year in which you did not earn more than the specified amount in wages and did not perform substantial services in self-employment. If no months were exempt, place an 'X' in 'NONE'. If all months were exempt, place an 'X' in 'ALL'. Refer to the instructions for the appropriate monthly limit.

Enter the total amount you expect to earn this year.

Check this box if you are earning wages of more than a specified amount per month.

Check this box if you are not earning wages of more than a specified amount per month.

Enter the dollar amount of your monthly earnings if you are earning wages of more than a specified amount.

Check this box if you, your spouse, or your prior spouse worked in the railroad industry for five years or more.

Check this box if you, your spouse, or your prior spouse did not work in the railroad industry for five years or more.

Enter the name and address of your employer. If you had more than one employer, list them in order beginning with your most recent employer. If you had no employers, write 'NONE'.

Enter the month (MM) when you began working for the first employer listed.

Enter the year (YYYY) when you began working for the first employer listed.

Enter the month (MM) when you stopped working for the first employer listed. If you are still working, write 'Not Ended'.

Enter the year (YYYY) when you stopped working for the first employer listed. If you are still working, write 'Not Ended'.

Enter the name and address of your second employer.

Enter the month when you began working for your second employer.

Enter the year when you began working for your second employer.

Enter the month when you stopped working for your second employer. If you are still working, write 'Not Ended'.

Enter the year when you stopped working for your second employer. If you are still working, write 'Not Ended'.

Enter the name and address of your third employer. If you need more space, use the 'Remarks' section.

Enter the month when you began working for your third employer.

Enter the year when you began working for your third employer.

Enter the month when you stopped working for your third employer. If you are still working, write 'Not Ended'.

Enter the year when you stopped working for your third employer. If you are still working, write 'Not Ended'. If you need more space, use the 'Remarks' section.

Enter the date (Month, Day, Year) when the event occurred.

Enter the name of the city and state where the event occurred.

Check this box if you do not expect to earn more than the specified amount in November of next year.

Check this box if you do not expect to earn more than the specified amount in December of next year.

Enter the amount you expect to earn next year if you are currently in the last 4 months of your taxable year.

Indicate the months next year in which you do not expect to earn more than the specified amount in wages or perform substantial services in self-employment. Place an 'X' in the appropriate boxes.

Check this box if you do not expect any months to be exempt months next year.

Check this box if you expect all months to be exempt months next year.

Check this box if you do not expect to earn more than the specified amount in January of next year.

Check this box if you do not expect to earn more than the specified amount in February of next year.

Check this box if you do not expect to earn more than the specified amount in March of next year.

Check this box if you do not expect to earn more than the specified amount in April of next year.

Check this box if you do not expect to earn more than the specified amount in May of next year.

Check this box if you do not expect to earn more than the specified amount in June of next year.

Check this box if you do not expect to earn more than the specified amount in July of next year.

If you use a fiscal year that does not end on December 31, enter the month your fiscal year ends.

Check this box if you are entitled to, or expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your Federal government employment and earnings.

Check this box if you are not entitled to, nor 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 Federal government employment and earnings.

Check this box if you currently receive a government pension or annuity. Fill only if the 'Entitled to a government pension or lump sum' is 'Yes'.

Check this box if you received a lump sum in place of a government pension or annuity. Fill only if the 'Entitled to a government pension or lump sum' is 'Yes'.

Check this box if you have applied for and are awaiting a decision on your pension or lump sum. Fill only if the 'Entitled to a government pension or lump sum' is 'Yes'.

This section provides a statement about the Paperwork Reduction Act, including the estimated time to complete the form and where to send it. No action is required here.

This section provides important information about changes in your work pattern, marital status, confinement, warrants, pensions, custody, disability, and other relevant changes that must be reported to the Social Security Administration. It also explains how to report these changes and the consequences of not reporting them. Please read this information carefully before answering question 18.

Check this box if you have Social Security credits (for example, based on work or residence) under another country’s Social Security system; if "Yes," answer (b).

Check this box if you do not have Social Security credits (for example, based on work or residence) under another country’s Social Security system; if "No," go to item 11.

Enter the name(s) of the other country or countries where you have Social Security credits under another country’s Social Security system. Fill only if the 'Do you have Social Security credits (for example, based on work or residence) under another country's Social Security system?' is 'Yes'.

Provide the language you prefer to speak if English is not your preferred language.

Provide the language you prefer to write if English is not your preferred language.

Describe how the marriage ended (e.g., divorce, annulment, death).

Enter the date (Month, Day, Year) when the marriage ended.

Enter the name of the city and state where the marriage ended.

Check this box if the marriage was performed by a clergyman or public official.

Check this box if the marriage was performed by someone other than a clergyman or public official and explain in the 'Remarks' section.

Enter the full name of your spouse, including her maiden name, at the time your marriage to the worker began.

Enter the month, day, and year when your marriage to the worker began.

Enter the name of the city and state where your marriage to the worker took place.

Enter the reason your marriage to the worker ended (for example, divorce, annulment, or death of spouse); if still in effect, write "Not Ended."

Enter the month, day, and year when your marriage to the worker ended.

Enter the name of the city and state where your marriage to the worker ended.

Check this box if the marriage was performed by a clergyman or public official.

Check this box if someone other than a clergyman or public official performed the marriage and explain in "Remarks."

Enter the name of your spouse (including maiden name) if you remarried after your divorce from the worker. If you did not remarry, write 'None'.

Enter the date (Month, Day, Year) when you remarried after your divorce from the worker.

Enter the city and state where you remarried after your divorce from the worker.

Describe how your marriage ended (e.g., divorce, annulment).

Enter the date (Month, Day, Year) when your marriage ended.

Enter the city and state where your marriage ended.

Check this box if the marriage was performed by someone other than a clergyman or public official. Provide details in the 'Remarks' section.

Check this box if the marriage was performed by a clergyman or public official.

Enter the name of your spouse (including maiden name) for any marriage that lasted at least 10 years, ended due to the death of your spouse, or if you remarried the same individual within a year after divorce and the combined period of marriage totaled 10 years or more. Use the 'Remarks' section for additional information. If none, write 'None'.

Enter the month, day, and year when you believe your medical condition(s) became severe enough to keep you from working. Fill only if the 'Unable to work in past 14 months due to illness, injuries, or conditions' is 'Yes'.

Check this box if you want to enroll in Medicare Part B (Medical Insurance).

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

This section provides information about Medicare coverage, including Part A and Part B. It explains the benefits, enrollment process, and premium details. Complete this section only if you are within 3 months of age 65 or older.

This section explains the late enrollment penalty for Medicare Part B and provides information about Medicare prescription drug plans (Part D). It also includes details on how to get help with prescription drug costs if you have limited income and resources.

Check this box if the month of August is relevant to your application.

Check this box if the month of September is relevant to your application.

Check this box if the month of October is relevant to your application.

Check this box if the month of November is relevant to your application.

Check this box if the month of December is relevant to your application.

Select this checkbox if none of the months apply.

Select this checkbox if all months apply.

Select this checkbox if January applies.

Select this checkbox if February applies.

Select this checkbox if March applies.

Select this checkbox if April applies.

Select this checkbox if May applies.

Select this checkbox if June applies.

Select this checkbox if July applies.

Select this checkbox if August applies.

Select this checkbox if September applies.

Select this checkbox if October applies.

Select this checkbox if November applies.

Select this checkbox if December applies.

This is an informational message indicating that you have reached the end of the form. If you press the tab key again, you will be taken back to the beginning of the form.

Check this box if you have not applied for but expect to begin receiving your pension or annuity. Fill only if the 'Entitled to a government pension or lump sum' is 'Yes'.

Enter the month and year you began receiving or expect to begin receiving your government pension, annuity, or lump sum based on your Federal, State, or local employment. If the date is not known, enter "Unknown". Fill only if the 'Entitled to a government pension or annuity' is 'Yes'.

Enter your date of birth in month, day, and year format.

Enter the city and state, or foreign country, where you were born.

Enter your full name at birth (first name, middle initial, last name) if it differs from the name you provided in item 2(a).

Check this box if you have used one or more names other than your birth name.

Check this box if you have not used any other names.

List any other names you have used (such as maiden name or any legal name changes). Fill only if the 'Have you used any other name(s)?' is 'Yes'.

Enter the name of the person applying for the Social Security benefits.

If the worker's surname is different from the claimant's, enter the worker's surname here.

Enter the Social Security Number of the claimant.

This section contains the Privacy Act Statement, which explains how the information you provide will be used and shared by the Social Security Administration.

This section lists changes that must be reported to the Social Security Administration, such as changes in address, citizenship, or work status. Enter the year for which you expect total earnings.

Enter the dollar amount of your expected total earnings for the specified year.

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

Check this box if you are not self-employed and not rendering substantial services in your trade or business.

Check this box if you have used any other Social Security number(s).

Check this box if you have not used any other Social Security number(s).

Enter any additional Social Security numbers you have previously been issued. Fill only if the 'Have you used any other Social Security number(s)?' is 'Yes'.

Enter the spouse’s date of birth (month, day, year) or, if the exact date is unknown, enter their age.

If the spouse is deceased, provide the date of death (month, day, year).

Enter the spouse’s nine-digit Social Security Number, or indicate “None” or “Unknown” if they do not have a number or it is not known.

Enter your spouse's date of birth or age.

If your spouse is deceased, enter the date of their death.

Enter your spouse's Social Security Number. If none or unknown, indicate as such.

Enter your spouse's date of birth or age.

If your spouse is deceased, enter the date of death.

Enter your spouse's Social Security number. If none or unknown, indicate so. Use the 'Remarks' space on page 5 for information about any other marriages. If you are now under full retirement age or less than one year past full retirement age, answer question 13. If you are more than one year past full retirement age, go to question 14.

Indicate if you want to file for Supplemental Security Income if you are within 2 months of age 65 or older, blind, or disabled.

Indicate if you do not want to file for Supplemental Security Income if you are within 2 months of age 65 or older, blind, or disabled.

If the application is signed by mark (X), two witnesses who know the applicant must sign here and provide their full addresses. Also, print the applicant's name in the Signature block.

Enter the full address (number and street, city, state, and ZIP code) of the first witness.

If the application is signed by mark (X), the second witness must sign here.

Enter the full address (number and street, city, state, and ZIP code) of the second witness.

Indicate the months of the current year in which you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment. Mark 'NONE' if no months are exempt, or 'ALL' if all months are exempt.

Select 'None' if no months are exempt from the earnings limit, or 'All' if all months are exempt.

Select this checkbox if all months of the current year are exempt from the earnings limit.

Select this checkbox if January is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if February is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if March is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if April is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if May is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if June is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if July is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if August is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if September is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

Select this checkbox if October is an exempt month where you did not or will not earn more than the specified amount in wages, and did not or will not perform substantial services in self-employment.

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

Check this box if you are, or during the past 14 months have not been unable to work because of illnesses, injuries, or conditions.

Enter the wage earner’s full name, including first name, middle initial, and last name.

Enter the wage earner’s nine-digit Social Security Number.