Form 753 PDF Details

Navigating through the maze of Social Security Administration (SSA) forms can sometimes feel daunting, especially when faced with the Form SSA-753, Statement Regarding Marriage. This particular form is a crucial piece of documentation used to establish the marital relationship between individuals for the purpose of determining eligibility for Social Security benefits. It mandates the input of various pieces of information including the worker's Social Security Number, personal testimony regarding the nature of the relationship between the worker and the applicant, and detailed questions aimed at ascertaining the legitimacy of the marital status claimed. Respondents are required to disclose their relationship to the worker and the applicant, how long and in what context they have known each individual, their opinion on whether the couple lived together and presented themselves publicly as married, among other details. This form also provides space for additional remarks, ensuring that any unique scenarios or explanations can be thoroughly communicated. Completion of Form SSA-753 is declared under penalty of perjury, highlighting the importance and seriousness of the information being provided. Moreover, the form underscores the SSA’s commitment to privacy and data security, with comprehensive measures in place to protect the personal information collected throughout the process. As with many SSA forms, the SSA-753 is pivotal for the accurate and timely processing of benefit claims, making it imperative for applicants and those providing statements to understand its scope and significance fully.

QuestionAnswer
Form NameForm 753
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesssa 753 forms, ssa 753, social security form 753, social security form statement online

Form Preview Example

Enter Worker's Social Security Number

Form SSA-753 (03-2018) UF

Page 1 of 3

Discontinue Prior Editions

 

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0017

STATEMENT REGARDING MARRIAGE

All questions must be answered or marked "Unknown." If you need more space for answers, continue them under "Remarks" on reverse side.

Print Name of Wage Earner or Self-Employed Person (Herein referred to as the "Worker".)

Print Name of Applicant

I understand that this statement will be considered in connection with an application by the applicant named above for payment of benefits under the provisions of Title II of the Social Security Act, as amended, based on the earnings of the Worker named above.

Print Your Full Name (First name, middle initial, last name)

1.What is your relationship to the Worker? (Mother, child, cousin, etc. - if not related, state "None.")

To the Applicant? (Mother, child, cousin, etc. - if not related, state "None.")

2. How long have you known the Worker?

The Applicant?

 

 

3.How often and on what occasions did you meet the Worker?

The Applicant?

4.

To your knowledge, were (are) the Worker and Applicant generally known as

Yes

No

 

a married couple?

 

 

 

 

 

 

 

5.

 

Yes

No

 

Did (do) you consider them married couple?

 

 

 

 

 

Give facts and explain fully the reasons for your belief:

 

 

6.

Did you hear them refer to each other as a spouse?

If "Yes," when and where?

Yes

No

Form SSA-753 (03-2018) UF

 

 

 

 

Page 2 of 3

 

 

 

 

 

 

 

7.

In your opinion, did (do) they maintain a home and live together as a married couple?

Yes

No

 

 

 

 

 

If ''Yes,'' where and when?

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY OR TOWN

STATE

 

DATES

 

 

 

 

 

 

 

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. To your knowledge, did they live together continuously?

Yes

No

If "No," explain.

 

 

9. To your knowledge, has either the Worker or the Applicant entered into any other marriage?

Yes

No

 

If ''Yes, '' give the following information regarding all such marriages.

 

 

 

 

 

 

 

 

 

 

 

 

STATE WHETHER

 

DATE AND PLACE OF

HOW MARRIAGE

DATE AND PLACE

 

WORKER OR

TO WHOM MARRIED

 

MARRIAGE

 

MARRIAGE

TERMINATED

 

 

APPLICANT

 

TERMINATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Remarks: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

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.

SIGNATURE OF PERSON MAKING STATEMENT

Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

Telephone Number (include Area Code)

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person making the statement must sign below, giving their full addresses.

1. Signature of Witness

2. Signature of Witness

Address (Number and Street, City, State, and ZIP Code)

Address (Number and Street, City, State, and ZIP Code)

Form SSA-753 (03-2018) UF

Page 3 of 3

 

 

Privacy Act Statement

Collection and Use of Personal Information

Section 216(h)(1)(A) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on the individual’s claim.

We will use the information you provide to establish an individual’s marital relationship and to make an eligibility determination for Social Security benefits. We may also share the information for the following purposes, called routine uses:

1.To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs; and,

2.To student volunteers, individuals working under a personal services contract, and other workers who technically do not have the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions.

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 (SORNs) 60-0089, entitled Claims Folders Systems and 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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. We estimate that it will take about 9 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.

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This form will require specific information to be filled in, thus make sure you take whatever time to type in exactly what is required:

1. Fill out the how to social security form marriage with a number of necessary blank fields. Collect all the necessary information and make sure nothing is missed!

Step no. 1 in filling out marriage form ssa

2. Just after filling in this step, head on to the next step and fill in the necessary particulars in all these blank fields - The Applicant, To your knowledge were are the, a married couple, Did do you consider them married, Give facts and explain fully the, Yes, Yes, Did you hear them refer to each, Yes, and If Yes when and where.

marriage form ssa conclusion process clarified (part 2)

3. Completing Form SSA UF, In your opinion did do they, Page of, Yes, CITY OR TOWN, STATE, DATES, FROM, To your knowledge did they live, If No explain, Yes, To your knowledge has either the, If Yes give the following, STATE WHETHER, and WORKER OR APPLICANT is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

marriage form ssa completion process clarified (step 3)

Always be extremely careful while completing Page of and Form SSA UF, as this is where many people make errors.

4. To go forward, the following form section will require completing a handful of blank fields. Examples of these are Remarks This space may be used for, I declare under penalty of perjury, Signature First name middle, Date Month day year, SIGNATURE OF PERSON MAKING, Telephone Number include Area Code, and Mailing Address Number and Street, which you'll find essential to continuing with this particular document.

Find out how to prepare marriage form ssa stage 4

5. This form must be finished with this particular section. Further there's a full listing of blanks that have to be filled out with specific information to allow your document submission to be accomplished: City and State, ZIP Code, Witnesses are required ONLY if, Signature of Witness, Signature of Witness, Address Number and Street City, and Address Number and Street City.

marriage form ssa conclusion process clarified (portion 5)

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